Inquests & Inquiries
Admitted failings in Article 2 inquests needn’t be part of the Coroner’s conclusion
Read Jamie’s post on our UK Inquest Law Blog.
Geoff Gray Inquest – Deepcut Barracks : Coroner returns a conclusion of ‘suicide’
Bridget Dolan KC and Jamie were instructed as Counsel to the Inquest in the fresh inquest into the death of Geoff Gray.
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Experience & Expertise
Jamie was trained during pupillage by inquests specialist and Assistant Coroner Bridget Dolan KC, assisting her with her work as Counsel to the Inquest during the Inquests into the deaths of seven British nationals in the terrorist attack at the In Amenas gas plant in Algeria. During pupillage he also assisted barristers working on the Hillsborough Inquests and the Inquest into the death of Amy El-Keria.
Following this, Jamie was led by Bridget Dolan KC as Counsel to the Inquest in each of the fresh Inquests into deaths at Deepcut Barracks in 1995 and 2001, investigating the circumstances of the deaths by gunshot wounds of Cheryl James (HH Judge Barker CBE QC, 2016), Sean Benton (HH Judge Rook QC, 2018) and Geoff Gray (HH Judge Rook QC, 2019). All three deaths took place amid allegedly widespread bullying and assault of army trainees.
Jamie was continually involved in all aspects of these major cases, each involving over 100 witnesses, thousands of pages of disclosure, and complex forensic evidence, all under the spotlight of intense media interest and speculation. He has experience, rare in his level of call, of high-profile Judge-led inquests, and of dealing with challenges such as: making arrangements for exhumation; disputed ballistics and pathology evidence; witnesses being based outside the jurisdiction; inquests involving investigation into potentially criminal conduct; and disputes over the admissibility of previous bad character.
Jamie is regularly instructed in inquests involving:
- Potential medical negligence
- The application of Article 2 ECHR
- Health and safety issues and potential criminal prosecution
- Deaths in care homes, including the deaths of residents subject to deprivation of liberty safeguards
- Deaths in prison
- Deaths under Mental Health Act detention or following discharge
- Deaths involving alleged failings by state bodies, including admitted failings involving the application of Tainton.
- Potential reports into the prevention of future deaths
On behalf of families:
- SS , arising from the suicide of a middle-aged woman suffering from depression, shortly after discharge from hospital and handover between clinical teams. The Coroner made an exceptional ‘prevention of future death’ report to the GMC and NICE regarding an evident lack of understanding by clinicians of how hormone changes might have affected her during the menopause, raising issues at a national level of how women with mental health issues might be better supported.
- TY , acting for the parents of a baby who died shortly after being born. The Coroner made a finding of neglect, as a pathological CTG had been repeatedly misinterpreted, and also made a PFD report arising from her concerns about post-inquest investigations. A subsequent claim, including damages for the mother’s own psychiatric injuries, was successfully settled.
- NL , representing the widower of a woman who had died from sepsis after a spell on a private ward following bowel surgery. The Coroner found numerous failings in care and returned a narrative conclusion that NEWS scores had been inadequately acted upon. A Fatal Accidents Act claim was subsequently settled for a six-figure sum.
- EJD [2018 – 2020], where an elderly lady died of a fall in a care home following the first administration of a newly prescribed sedative, with care home staff giving wildly differing accounts and making allegations that records had been doctored or destroyed, leading to prolonged criminal investigation. The Coroner made criticisms of her care and her family received a settlement after the inquest.
- FH , where a man died from faecal peritonitis following bowel surgery amid what the Coroner found to be inadequate safety-netting advice.
- RG , representing a bereaved family at an Inquest into the death of a man from a drugs overdose at a music festival, featuring seven other Interested Persons.
- PW [2016-2017], instructed on behalf of the widower of a 69-year-old woman who had died from sepsis two days after being turned away from A&E. After several part-heard hearings, the Coroner returned a narrative conclusion finding that the death had been contributed to by neglect, and directly referred the A&E Consultant who had discharged PW to the GMC. There were significant factual disputes between Jamie’s client and the Consultant, multiple applications for adjournment by the Consultant’s representatives, and arguments over the admissibility of evidence. Following the Inquest, the family were offered damages by the NHS Trust, which had previously denied liability in its Letter of Response.
- BM , for the parents of a three-year-old who died from a secondary infection following chicken pox. The Coroner returned a narrative conclusion setting out that an opportunity for doctors to prevent her death had been missed. BM’s family subsequently received damages after the NHS Trust responsible admitted negligence.
- KS , questioning eight doctors and two experts on behalf of a family investigating the complex background to the death of a woman with undiagnosed chronic liver disease who had suffered from years of unexplained abdominal symptoms.
- LDJ and NN , an Inquest into the death of two young women from traumatic asphyxiation in a nightclub crush. Only weeks after finishing pupillage, Jamie acted pro bono as the sole family representative during a two-week long jury inquest featuring five other interested persons, represented by senior counsel including a QC. After hearing evidence from victims, staff and emergency services, the jury returned a narrative conclusion stating that the safe exit of clubbers had not been adequately considered by club management and that a lack of oversight had contributed to the deaths.
Jamie is happy to act on a CFA basis for families considering a potential claim after the inquest, and also where appropriate will protect family participation in the inquest process by acting pro bono. He is direct access qualified.
Representing individual clinicians:
- SC , acting for a GP who had an appointment with a distressed patient just hours before he took his own life at home. The court made no criticism of her decision-making or risk assessment.
- IR , representing a speech and language therapist who had assessed a hospital patient who subsequently died whilst eating and allegedly underestimated his choking risk. She was the subject of concurrent HCPC proceedings. The case presented the challenge of protecting her professional position in a context where the NHS Trust had produced a critical SI report, which emphasised her involvement, despite pathological evidence that choking could not in fact be proven to be the cause of death.
- RF , representing a GP facing scrutiny of her response to a 3-week old baby, showing non-specific signs of acute illness, who subsequently died from heart failure. The GP, who faced critical comment in both an NHS Trust’s investigation report and from an expert, was not criticised by the Coroner.
- KC , acting for a doctor questioned over the prescribing of sodium valproate to a young woman whose baby died following a termination of pregnancy.
- PC , representing two GPs and a nurse from the same surgery, all of whom had been involved in assessing a man who died from undiagnosed appendicitis.
- PL , acting for a locum surgeon, who disputed the findings of a Trust SI report that his conduct was the root cause of the death of a woman from an iatrogenic injury to her liver.
- OW , Jamie represented a Consultant Paediatrician during six days of hearings into the tragic death of a baby from Persistent Pulmonary Hypertension of the Newborn, where there were factual differences between several different doctors and nurses, and critical allegations made both by the bereaved family and between the different clinicians. The factual and medical background was extremely complex. Legal matters were also in dispute with the Coroner inviting submissions both before and during the Inquest on whether Article 2 was engaged.
- AD , representing a trainee GP at a three-week Article 2 jury Inquest into the death of a man with learning disabilities from an undiagnosed ulcer whilst deprived of his liberty in a care home. The Coroner directed the jury that they were not as a matter of law to make any judgmental comment regarding Jamie’s client.
- IS , acting for a GP Practice Nurse at an Inquest into the death of a 94-year-old woman from a subdural haematoma. The Coroner concluded that Jamie’s client had monitored the deceased’s anticoagulation entirely properly, amid criticisms from her family.
- IG , acting for two GPs at a week-long Inquest into the tragic death of a 17 year old from meningitis.
- AW , where Jamie’s client was a GP in a jury inquest into the unexplained death of a woman detained under the Mental Health Act from necrotizing fasciitis. The jury returned a conclusion of natural causes.
Acting for institutions and corporate bodies:
- LQ , acting for the owners of a care home, with an ‘inadequate’ CQC rating and subject to a major safeguarding enquiry, in which a resident had died following a fall caused in part by a contractor failing to follow proper health and safety procedures. The inquest took place in the context of a potential for criminal action by the CQC against the care home.
- RV , a tragic case of suicide at a railway station by a young woman with a long history of mental health issues and alcohol abuse. Amid intense scrutiny on the operation of mental health services, the case led the NHS Trust to carry out an audit of its entire case load.
- RF , a case of death in prison due to ‘spice’ toxicity, prompting investigation into widespread drug use in prisons and standards of risk assessment of prisoners with mental health issues or dealing with bereavement who might have access to drugs. The Coroner also considered the co-ordination between different providers of medical and mental health support in the prison, raising questions of wider significance concerning the quality of communication between commissioned private providers in the public sector.
- CS , representing children’s social services who had made the decision to ask the Court to remove children from a mother who subsequently died from a drug overdose.
- MW , acting for a social worker whose long-standing client, with very complex mental health issues, died from frailty and chronic malnutrition. The deceased had been the subject of Court of Protection proceedings over whether it was in her best interests to be forcibly fed.
- KS [2019-2020], representing a charity facilitating shared lives living schemes concerning the tragic death of a man with Down’s Syndrome in a carer’s home. The deceased’s family, represented by a QC, raised allegations of gross negligence and neglect which were rejected by the court.
- BAA , a case where a prisoner was found hanged in her cell. Jamie represented the NHS Trust responsible for prison healthcare, including the psychiatrist who had assessed her risk of self-harm.
- SH , regarding the death of a young woman whilst detained under section, representing the NHS Trust responsible for her psychiatric care.
- HH , acting for the provider of supported living after a resident, recently discharged from hospital, suffered a fatal overdose of drugs.
- HB , instructed by a local authority whose health and safety officers were facing scrutiny over their handling of a case where an elderly lady in a care home had suffocated during the night.
- CF , acting for an NHS Trust where a child had died from a haemorrhage following an operation.
- JR , for an NHS Trust whose patient had died from sepsis following an operation. The circumstances leading to his hospitalisation were the subject of potential litigation and media interest.
Jamie also has the rare experience of proceedings under the Presumption of Death Act 2013, successfully obtaining an order in the Chancery Division settling the affairs of a missing person on behalf of his family.
Jamie is recommended by both The Legal 500 and Chambers & Partners as a leading junior in inquests and public inquiries. Recent editorial has noted:
“Very bright, hands-on and great with clients. He is good on his feet and has become incredibly busy.”
Chambers & Partners, 2022
“Extremely hard-working…he can hold his own against people well above his call.”
The Legal 500, 2021
“Approachable and knowledgeable. I trust Jamie to put clients at ease and get the best possible outcome for the client.”
The Legal 500, 2020