Key takeaways
High Court grants fresh inquests
New evidence justified quashing original conclusions.
Public interest drives re-investigation
Fresh inquests may affirm or revise findings.
Case sets threshold for new inquiries
Evidence must directly impact cause of death.
The Claimant Coroner successfully applied to the Administrative High Court for quashing orders in two inquests where new information relevant to the cause of death arose.
Summary
Adopting the reasoning in HM Attorney General -v- HM Coroner of South Yorkshire (West) [2012] EWHC 3783 (Admin) (‘the Hillsborough case’), the Administrative Court found that where new pertinent information arises that would likely change the conclusion reached at inquest, it is in the public interest and interests of justice, for the original findings to be quashed and a new inquest heard. Importantly, it is not a requirement that new information would result in a different conclusion; a fresh inquest may also be indicated where significant new information would affirm the conclusions of the original inquest.
Background
The case concerns two inquests held in 2013 and 2017 respectively. On the facts available at the time, HM Senior Coroner for Cornwall And the Scilly Isles (“the Coroner”) concluded that the deaths of Edward John Masters and Mary Helen Rooker had been from a recognised complication of necessary surgery. Both patients had undergone elective surgery for the repair of an abdominal aortic aneurysm, under the care of the same surgeon at the vascular surgery unit of the Royal Cornwall Hospitals NHS Trust (“the Trust”).
In January 2019 the Trust asked the Royal College of Surgeons to carry out an Invited Service Review (“ISR”) of its processes within the vascular surgery unit and specifically in relation to the consultant surgeon who provided care to both deceased.
The findings of the ISR review and fresh expert evidence raised serious concerns around patient safety within the vascular surgery department generally and pointed specifically to negligence on behalf of the treating surgeon.
Legal test
In light of these findings, the Coroner made an application to the Administrative Court under section 13 of the Coroners Act 1988. Section 13(1) of the Act gives power to the High Court to order a fresh inquest to be held when, inter alia, the ‘discovery of new facts or evidence’ makes it ‘necessary in the interests of justice’ for an inquest to be held. Section 13(2) gives the High Court power to quash the findings and conclusions of the Coroner at an inquest which was conducted based on incomplete information.
Given the significant failings identified in the care provided to the deceased, it was considered to be in the public interest for the Court to quash the findings from the first inquest and conduct a second inquest investigation, now that further evidence had become available.
The Administrative Court’s findings
The Administrative Court quoted paragraph 10 of the judgment in the Hillsborough case which helpfully sets out the the legal framework on application.
"The single question is whether the interests of justice make a further inquest either necessary or desirable. … the emergence of fresh evidence which may reasonably lead to the conclusion that the substantial truth about how an individual met his death was not revealed at the first inquest, will normally make it both desirable and necessary in the interests of justice for a fresh inquest to be ordered… It is not a pre-condition to an order for a further inquest that this court should anticipate that a different verdict to the one already reached will be returned…even when significant fresh evidence may serve to confirm the correctness of the earlier verdict, it may sometimes nevertheless be desirable for the full extent of the evidence which tends to confirm the correctness of the verdict to be publicly revealed.”
In the present case, the negligent care and failings identified in the ISR served as compelling evidence in favour of the Administrative Court making a quashing order in respect of the first inquests and ordering new inquests to be heard. It was sufficient that the failings on behalf of the Trust and treating surgeon raised the possibility of new findings being reached at inquest, albeit the Claimant Coroner did not have to argue a different conclusion was probable. It was (and will be) sufficient that where evidence of the sub-standard care provided was not available at the first inquest and this evidence held the ‘substantial truth’ about how the deceased patients died, a fresh inquest should be heard.
Key legal insights
Reflecting on this case, it may be helpful to think in very basic terms what the purpose of an inquest is, that is, an investigation to reach a conclusion as to who, when, where and how a person died. If key information relevant to any of those questions is unavailable, it follows that whatever findings are reached, it may be necessary to reconsider the evidence in its entirety, in order to complete the investigation and reach a conclusion.
It should also be said that the threshold of the relevance of new information is high – not every expert report obtained in a clinical negligence claim following the conclusion of an inquest will mandate a fresh inquest investigation. The evidence must be directly relevant to the core questions which an inquest seeks to answer.