Inquests & Inquiries
‘Michael is a fantastic strategist who hones in on the key issues of a case straight away. His advocacy is fantastic: persuasive and a pleasure to listen to.‘ The Legal 500
Michael is a contributing co-author of Medical Treatment: Decisions and the Law, 4th edition.
experience & expertise
Michael represents the full range of Interested Persons, including NHS Trusts, individual clinicians, nursing homes, and families, at Article 2 and jury Inquests, particularly where significant clinical issues are involved.
Mental health services comprise a large proportion of his practice, often dealing with scrutiny of alleged systemic failures in care and issues over mental capacity. He also advises on Judicial Review of Coroners’ decisions.
The range of Inquests in which Michael has appeared includes deaths arising:
- in secure psychiatric facilities (PICU and general psychiatric units) and whilst in community care;
- in detention (self-inflicted and following assault);
- in nursing homes (e.g. nutrition and pressure sore management issues);
- in the course of GP and hospital treatment (primary care and NHS / private hospital treatment, e.g. misdiagnosis and delays in treatment);
- on worksites (e.g. workmen crushed by plant on major city-centre developments;
- roofer falling through fragile roof of a renovated building; workman crushed by plant or vehicles being serviced); and
- from road traffic collisions, involving commercial vehicles, public service vehicles, and domestic motorcycles and cars (including deaths in the course of police pursuits).
cases & work of note
- In Re. Francis: Michael acts for a main provider of medical staff in police custody, where an intoxicated detainee died from sudden unexpected death in epilepsy. The matter is likely to require an inquest of several weeks later this year.
- In Re. H: Michael represented the family of a young adult who tragically took his own life shortly after leaving children’s social services. After a 2-week Article 2 inquest involving the police, GP, NHS Trust, and Adult and Children’s Social Services, the Coroner found his death was contributed to by Neglect. Civil proceedings are ongoing.
- In Re. Jones: Michael acted for one of the largest private providers of supported housing wherein a resident suffered a fatal choking incident (causative shortcomings in care having been admitted). Michael’s guidance resulted in no report for the Prevention of Future Deaths being required.
- In Re. Kilkowski: Michael represented East of England Ambulance Service in relation to a man suffering from Acute Behavioural Disturbance during a lengthy police restraint. After significant expert medical evidence during a 3-week Article 2 jury inquest, Michael’s clients (operating under difficult pandemic-related conditions) were found to have made no causative difference to his condition.
- In Re. S: Michael acted for the family whose 21-year-old daughter died after consuming internet-purchased Dinitrophenol (‘DNP’) slimming pills that caused her to fatally overheat, having been admitted to an overwhelmed NHS accident and emergency department. A week-long Article 2 Inquest heard expert evidence from international and national experts in forensic toxicology, pharmacology, and intensive care. In spite of the Suicide conclusion, significantly substandard care was identified in the Acute NHS Trust’s treatment of toxic substances, and a Prevention of Future Deaths report invited the Home Office to consider making it illegal to possess, sell, or purchase the drug in question in future. The Inquest attracted significant local and national media attention, and as a result of the family’s campaigning efforts, the substance will be classed as a poison from October 2023.
- In Re. Atkinson: Michael acted for a private healthcare provider’s mental health staff, who were caring for a female inmate in a Category A prison. The prisoner was found dead, having been previously viewed with a ligature around her neck for some time. Although there was criticism of the prison service staff’s response, the private healthcare provider’s mental health staff were in fact praised for their new Ligature policy, which was incepted to prevent a repeat of the circumstances surrounding the death in question.
- In Re. Masters: Michael acted for mental health Trust clinicians caring for a schizophrenic female patient with a significant self-harming history, who eventually died from self-inflicted injuries that lay undiscovered for a significant period. An 8-day Article 2 Inquest with a jury was required.
- In Re. C: Michael acted for paediatric hospital clinical staff caring for a 12-year-old female patient who succumbed to E. Coli in an immunosuppressed state following cancer treatment.
- In Re. S: Michael acted for a mental health nurse responsible for the care of an 18-year-old suffering from epilepsy and autism, who died whilst in the bath. A 2-week Article 2 Inquest with a jury ensued; attracting significant media attention.
- In Re. Renney: Michael acted for NHS Trust mental health clinicians caring for a female patient, who died from hanging using a previously unconsidered ligature point. A 3-day Article 2 Inquest with a jury was required.
- In Re. Gough: Michael acted for a private care home following the death of a resident whilst undertaking unsupervised personal care. Effecting a significant shift in the operative cause of death resulted in no adverse findings or PFDR matters against the care home.
- In Re. Esegbona: Michael represented a private national care home organisation, following the death of a resident receiving complex tracheostomy care. Extensive scrutiny of the care home’s national care standards allowed the matter to conclude with no adverse findings or PFDR matters against the care home.
- In Re. Lawrence: Michael represented a Trust at a 6-day Inquest following a young female inmate’s self-inflicted death. Adverse findings were likely to have had far-reaching implications for all mental health services provided for all young persons in custody. However, critical examination of all clinical expert evidence resulted in a Conclusion of Misadventure, with the jury expressing praise for the conduct of Trust staff, and no PFDR concerns.
- In Re. Holmes: Michael acted for a Trust in an aortic valve intervention case, following the misplacing of a valvuloplasty balloon. A conclusion of natural causes reflected the evidence that any inaccurate placing of the balloon during transcatheter aortic valve implantation was unrelated to the patient’s deterioration and death, and hence no PFDR matters arose.
- In Re. CNG: Michael acted for a Defendant Trust in a 3-week prison suicide Inquest invoking Article 2 ECHR.
- In Re. Kelly: Michael acted for the family of passengers that crashed during an alleged police pursuit.
- In Re. K: Michael acted for the family of a teenager that suffered a sudden unexpected death, following a suspected but unwitnessed seizure. A regulation 28 Report to Prevent Future Deaths was duly made in relation to paediatric neurology referrals that were deemed to contravene NICE guidelines.