Inquests & Inquiries
“An extremely experienced and able advocate”
Chambers & Partners
cases & Work of note
- West London Coroners Court, October 2018: Representing the West London Mental Health NHS Trust. Female Patient, having not taken recently her anti-psychotic medication and whilst having recently used cannabis, died by falling / jumping from the ninth floor of a block of flats in an act of suicide to which neglect contributed. Appropriate intervention by the Metropolitan Police proved unsuccessful.
- West London Coroners Court, September 2018: Representing the London Borough of Hillingdon as the Enforcing Authority responsible for inspecting food outlets at Heathrow Airport. Natasha Ednan-Laperouse, who was fifteen in July 2016 and known to suffer from numerous allergies, chose an artichoke, olive and tapenade baguette believed by her to be suitable for her but later found to contain within the dough sesame to which she was allergic, collapsed and died on a flight to Nice. The Inquest looked at the application of both European and National Food Applications and how they were applied by both small and large companies such as Pret a Manger.
- South London Coroners Court, March 2018: Representing a GP in the Ellie Butler Inquest before Dame Linda Dobbs DBE. Ellie Butler had been murdered by her Father, Ben Butler, who had been convicted and sentenced in June 2016 by Wilkie J at the CCC to imprisonment for life with a recommendation that he serve a minimum of twenty two years. Jennie Grey, Ellie’s Mother, who had been convicted of perverting the course of justice by lying in respect of the events on her return home following Ellie’s murder and child cruelty, was sentenced to imprisonment for forty two months. The scope of the Inquest was set to look at the period of time following the decisions by Hogg J in July and September 2012 to return Ellie to live with her Parents and the involvement thereafter of Social Services, the Independent Social Workers approved by Hogg J, the Schools attended by Ellie and the GP’s Practice.
- Surrey Coroners Court, October 2017: Representing a GP, with whom a sixty four year old male resident in a care home was registered as a patient. The patient had suffered all his life from autism, severe behavioural and learning difficulties and a disorder called ‘Pica’, whereby he picked up and ate items with no nutritional value such as cigarette ends. The patient, who had spent most of his life in care and / or residential homes, was unable to communicate with anyone. The patient was under the care of the local Mental Health Team, led by a Consultant Psychiatrist and as such the Team was responsible for supervising his anti-psychotic medicine, which was prescribed by the GP at the Team’s direction. Although the patient was reviewed and seen from time to time by the GP and his Partners, none of them had any clinical involvement in the patient’s final illness leading to his death from a gastric haemorrhage caused by a bleeding gastric ulcer. Advice was sought from the home’s own doctor who did not visit but who suggested that the patient was likely to be constipated and should receive appropriate medication. The Jury were extremely critical not only of how the home was managed and run but also of the care that the patient had received and concluded that those failures were gross and to which neglect had contributed. However there was no criticism of the GP and / or his Partners.
- Surrey Coroners Court, June 2017: Representing a Nurse, who was one of two Nurses involved in the drawing up and priming of a giving set to dispense phenytoin, prescribed by or under the direction of a Consultant, which led to the death of a female patient. Inquest adjourned part heard at the request of the Police to enable them to carry out further inquiries.
- Nottingham Coroners Court, November 2016: Representing a Consultant Anaesthetist, who was not the Surgeon’s usual Consultant Anaesthetist and operating partner, involved in complex high-risk spinal revision surgery for a female patient, from whom the obtaining of informed consent had included the risks of haemorrhage and death. HM Coroner found that there were a number of communication failings pre-operatively, intra-operatively and post-operatively. The intra-operative failings resulted in the patient suffering a massive haemorrhage which caused hypoxic brain inquiry and led directly to the patient’s death.
- Oxford Coroners Court, October 2015: Representing one of two named nurses responsible for the care of an 18 year old male resident in a care home, diagnosed as an epileptic and suffering from a learning disability, found to have drowned in a bath. The male resident was known by the staff to have a habit of taking not showers but long baths and at times when there was little or minimal supervision of him. Both the NHS Mental Health Trust that owned and managed the care home and the staff were heavily criticised by the Jury as the death was preventable. Neglect was found to have contributed to the death in numerous respects, including a failure by the staff to carry out an adequate assessment of the care and risk management of a resident diagnosed as an epileptic with a learning disability, a lack of clinical leadership and a lack of adequate training and guidance by the management for the nursing staff.
- Manchester South Coroners Court, April 2015: Representing The Priory Hospital at Cheadle Royal where a 17 year old female adolescent patient with a known history of self-harm tied a ligature of a wire from a spiral bound notebook around her neck following an extended and brilliant period of home leave and at a time where her observation levels had been reviewed and reduced on clinical grounds by her multi-disciplinary team and at a time when NHS England and others were seeking to find the adolescent patient a suitable therapeutic placement in the community.
- Cumbria Coroners Court, February 2015: Representing The North Cumbria University Hospitals NHS Trust on behalf of the West Cumberland Hospital, where a 19 year old female patient with a significant cardiac history underwent an appendicectomy during which an intra-abdominal haemorrhage was caused but not recognised immediately leading in a matters of hours to a cardiac arrest and death from hypoxic brain damage.
- South Yorkshire Coroners Court, November 2013: Representing a spinal surgeon, who whilst performing a discectomy on a middle aged female patient, entered the spine at the wrong level, at L4/5 and not L5/S1, damaging an artery in the process and causing an intra-peritoneal haemorrhage which was not recognised immediately and which led in a matters of hours to a cardiac arrest and subsequent death.
- Inner London West Coroners Court, July 2013: Representing two ambulance paramedics called to attend a patient who had collapsed in a London street whilst in police custody and who was later to die whilst in police custody at a nearby police station.
- The Inquiry into Hyponatraemia Related Deaths, Belfast: March 2012 and presently ongoing as the Report is still due: an Inquiry, chaired by Mr Justice O’Hara, into five deaths of children and young persons at The Royal Belfast Hospital for Sick Children during the years 1995-2004. Deaths said to have been caused by or related to hyponatraemia, representing in turn two Consultant Paediatricians.
- Pontypridd Coroners Court: The Cwm Taf NHS Trust, March 2010: Male Patient in his late 40s, a smoker and heavy drinker consented for a hemi-glossectomy, tracheostomy performed but then malignancy found to have extended over the midline of the tongue. Patient awakened, findings explained. Options given – chemotherapy or a total glossectomy: former chosen. During a subsequent changing of the tracheostomy tube, a false tract established, causing in time a weakness leading to a fatal bleed. Trust criticised by the Public Services Ombudsman for Wales for numerous failings. The issue for consideration by HM Deputy Coroner for the Valleys, sitting alone, was whether there was evidence of gross negligence manslaughter based on the replacing of the tracheostomy tube, establishing the false tract. However such evidence was not supported by the Ombudsman’s Surgical Expert. A Narrative Verdict returned.