Drysdale: inquests and theoretical causes – lessons for NHS organisations

A new inquest decision explores the extent to which an inquest must pursue theoretical possibilities particularly when those are not supported by robust evidence. 

Sasha Drysdale died on 28 March 2023 while an inpatient on a psychiatric unit. She had schizoaffective disorder, which was being treated with clozapine, an antipsychotic. Sasha’s medical cause of death was acute myeloid leukaemia (AML) transformed from myelodysplastic syndrome.

The inquest in July 2024 explored the relationship between Sasha taking clozapine, and her death. During evidence, a treating haematologist was asked whether the clozapine contributed to the development of AML in a way that is ‘more than minimal, more than negligible, or more than trivial’. In response, the haematologist noted that they ‘don’t think there is sufficient evidence known in the medical literature to make that link’.

The inquest jury ultimately returned a conclusion of death due to natural causes. The coroner issued a Prevention of Future Deaths (PFD) report on the monitoring of clozapine and possible links with blood cancers.

Following the inquest, an application for judicial review was made by Sasha’s brother, arguing that the Coroner (a) wrongly prevented certain questions being asked of the haematology expert regarding the link between clozapine and AML, and (b) wrongly decided not to leave the possibility of a neglect verdict to the jury.

The Court’s decision

The High Court dismissed the claim, holding that:

• It was not unlawful for the Coroner to prevent questions asked by the Claimant to the haematologist; and
• There was a lack of evidence to support a conclusion of neglect in the inquest; the Judge noted that ‘there was simply no material from which the jury could reach the conclusion that the neglect was gross, and accordingly it was not appropriate to leave the issue to the jury’.

Practical lessons for NHS Trusts and Integrated Care Boards (ICBs)

This case highlights several important points for NHS organisations involved in inquests:

• Scope – The scope of an inquest is a discretionary matter for the Coroner, and Coroners are entitled to curtail speculative questioning. 
• Causation – The test for causation remains whether an event more than minimally, negligibly or trivially contributed to the death. The Drysdale judgment underlines that inquests are not vehicles for exploring every theoretical possibility.
• Neglect bar remains high – To justify a finding of neglect, there must be a gross failure to provide basic medical attention and a clear and direct causal link with the death.
• Civil liability excluded – Inquests are not negligence trials and cannot determine civil liability.
• PFD readiness – Even if causation cannot be proved, Coroners may raise wider safety concerns through PFD reports. Trusts and ICBs should be ready to respond promptly and constructively if required.

If your organisation requires support with an inquest, please get in touch with our team of experts.