Dodgy Conclusion Avoidance

The Importance of Obtaining Proper Reasons for your Coroner’s Decision-Making

Inquests are difficult affairs at the best of times. What makes things worse is when the Coroner makes a mess of their directions to the jury, the conclusion gets struck down by the High Court, and everyone ends up having to go through the entire exercise all over again.

That is what has happened in the sad case of R (Lewis) v Senior Coroner of West Kent. You can read the report published yesterday here.

It concerned a woman with a history of paranoid schizophrenia and obesity. She had bariatric surgery in 2010 and was sectioned shortly after. In 2014 she was moved to a psychiatric unit. In the following 3 years her physical condition deteriorated badly. She suffered hair loss, poor eyesight, under-nourishment, bed sores and much more besides. All this led to her death caused by malabsorption due to her bariatric surgery.

A clinician witness was critical of the physical care provided by the psychiatric unit. A jury finding of neglect was in the air.

Coroners out there looking to orchestrate JR-proof conclusions, take note. This is not how you do it. The Coroner decided against leaving a finding of neglect to the jury. No indication was given of this prior to summing up. No real explanation was provided for why it was not safe to leave the issue of neglect to the jury.

A complaint from the family led to bland, unreasoned, and opaque references to coronial case law. The jury’s conclusion was malnutrition – the deceased had not received proper nourishment and nutrition at the psychiatric unit.

Unsurprisingly, the High Court took a dim view of the Coroner’s approach.

The failure to give reasons was described as “unfortunate”. The Court could not see, in the circumstances revealed in evidence, why a conclusion of neglect could not be left to the jury. The Court held the decision to withhold this issue from the jury was not properly open to the Coroner and the jury’s conclusion was quashed. The family and the staff will now have to relive the whole experience again.

Point to take away

All this highlights the importance of prompting the Coroner for an indication of what they are considering leaving to the jury prior to summing up. An appropriately timed interjection from an advocate will ensure you are forewarned about any nasty surprises. It will also ensure that all issues are properly aired at the inquest and that the dirty laundry does not end up in the High Court.

Stuart Knowles

Alex Pleydell

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