The importance of full disclosure: if in doubt, speak up, and let the Coroner decide

The inquest into the death of 22-year-old Sally Mays has been quashed with a fresh inquest ordered under section 13 of the Coroners Act 1988. The application, brought by Sally’s parents as the Claimants arose after new evidence was presented to the Coroner, after having already reached his conclusion.

In July 2014, Sally, who suffered with longstanding mental health difficulties, presented to her local Psychiatric Inpatient Unit accompanied by her Community Psychiatric Nurse. The CPN felt that Sally was at risk of fatal self-harm and sought for Sally to be admitted to the unit. Sally was refused admission, a decision which was heavily criticised by the Coroner during the inquest. Later that evening Sally died of asphyxiation and overdose.

Following conclusion of the inquest, the Senior Coroner was made aware of a conversation which took place between the CPN and a Consultant Psychiatrist as the CPN was leaving the unit, shortly after Sally had been refused admission. This conversation had not been referred to at any stage beforehand, and had not been examined as part of the evidence available to the Coroner during the inquest process. While the Claimants made no criticism of the Senior Coroner, and did not seek to challenge his overall conclusion, they successfully argued that this additional evidence could have contributed to findings of fact and may have been an essential element of organisational learning. As such, the High Court found that the duty imposed by Article 2 had not been fully discharged here, and ordered a new inquest, with the previous inquest being quashed.

This case clearly highlights the importance of thorough disclosure of all information held by witnesses. The witnesses felt that the conversation was not clinical in nature, and as such did not contribute to the escalation process. The important lesson here for witnesses seems to be: if in doubt, speak up, and let the Coroner decide if the information is relevant.


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