Inquests & Inquiries
“A responsible lawyer with a growing reputation.”
The Legal 500
Sarah Simcock acted for the London Ambulance Service in the 8 inquests into the deaths as a result of the London Bridge and Borough Market terror attacks
experience & expertise
Sarah has a wealth of experience in difficult and sensitive inquests, including those conducted under Art 2 and with a jury, sometimes attracting significant publicity. Her coronial experience spans various areas of particular expertise. Sarah is known for her knowledge and practical approach which instils confidence in her clients.
Deaths in Custody
Sarah regularly acts in inquests in relation to deaths in police and prison custody, involving force or restraint used by police officers or resulting from self-harm. Sarah has represented police forces as well as the Ministry of Justice, during her time as Treasury Counsel.
She continues to represent bodies who provide healthcare services in prisons as well as individual medical professionals such as prison GP’s. These inquests usually involve not only inquiry into the actions of individuals but also in relation to the workings of the system and the application of guidance, policies and training. Sarah is often involved in Art 2 inquests resulting from a death of a person detained in a psychiatric institution. These inquests highlight the cross-over between a custodial and a medical context and Sarah’s practice in both the police and clinical negligence and health care fields is an asset in this regard.
Sarah also regularly acts in inquests where a death has occurred following contact with the police either as a result of firearms operations, an arrest or as a result of ongoing involvement with child protection issues or the protection of vulnerable adults as well as mental health issues.
Deaths in a Medical Context
Sarah often represents families, NHS Trusts, private healthcare bodies and individual clinicians in inquests involving medical deaths both in relation to hospital care and primary care in the community. These involve a wide variety of issues including surgical deaths and deaths from infective processes such a c-diff or MRSA or as a result of drugs prescriptions or failure or delay in diagnosis of life threatening conditions.
Sarah also regularly advises on judicial review of coroners’ decisions and on complex issues of disclosure and public interest immunity.
The Emergency Services
Sarah has regularly acted for the emergency services other than the police, such as the London Fire Brigade and various ambulance services. Often the nature, quality and speed of the emergency response are in issue and the question of whether there is a causal connection to the death. Often policy and resources are relevant. In representing the emergency services Sarah is also often seeking to assist the coroner with the expertise the emergency services witnesses hold in an area that is often not well understood.
Sarah acted for the London Ambulance Service in the 8 inquests in relation to the victims who were killed in the terror attack that took place on London Bridge and in Borough Market on 3 June 2017. The London Ambulance Service, provided care and treatment at the scene to some of the deceased as well as the other victims of the attacks. The Coroner conducted a wide-ranging inquiry into how the deceased came by their deaths as well as the overall response of the emergency services, including the LAS, to the attack. The Chief Coroner, HHJ Lucraft QC, recorded determinations of unlawful killings in relation to each deceased along with narrative conclusions that reflected that the injuries of those who died were unsurvivable. The Chief Coroner will consider whether to make a report to prevent future deaths in relation to potential improvements which could be made to systems and procedures to ensure the emergency response to such complex incidents is as effective as possible in the future.
Sarah also acted for the London Ambulance Service in the 52 inquests into deaths as a result of the 7/7 London bombings. This inquest comprised a wide-ranging inquiry into individual deaths, in particular the issue of survivability, whether those who were injured by the bomb blasts, but did not die immediately, could have been saved, perhaps by different or more timely action by the emergency services. Hallett LJ, sitting as coroner, came to conclusions that in all those cases where the person had succumbed to their injuries nothing could have been done to save them. Hallett LJ also made an in depth inquiry into the quality and nature of the emergency response generally with a view to making recommendations to prevent future deaths.
“Brilliant with witnesses and so on top of the facts and the law.”
Chambers & Partners
“Highly valued for her wealth of knowledge and experience in representing doctors.”
The Legal 500
“She has a good practical approach and instils confidence in clients.”
The Legal 500
“Specialises in coronial law.”
The Legal 500
cases & Work of note
- Inquests arising from the deaths in the London Bridge and Borough Market terror attack
Acting for the London Ambulance Service. The inquest concerned eight victims who were killed in the attack that took place on London Bridge and in Borough Market on 3 June 2017. The London Ambulance Service, provided care and treatment at the scene to some of the deceased as well as the other victims of the attacks. The Coroner conducted a wide-ranging inquiry into how the deceased came by their deaths as well as the overall response of the emergency services, including the LAS, to the attack. The Chief Coroner, HHJ Lucraft QC, recorded determinations of unlawful killings in relation to each deceased along with narrative conclusions that reflected that the injuries of those who died were unsurvivable. The Chief Coroner will consider whether to make a report to prevent future deaths in relation to potential improvements which could be made to systems and procedures to ensure the emergency response to such complex incidents is as effective as possible in the future.
- Inquest into the death of Sylvia Bravery (2017)
Representing a Consultant Surgeon who carried out complex extensive surgery for the removal of cancer of the uterus on the deceased. During the surgery the surgeon mis-identified the pancreas as a cancerous lymph node and inadvertently removed it leading to the leaking of pancreatic fluid onto surrounding structures causing multi-organ failure. The surgeon had fully admitted the error which was found to be directly causative of the death. The coroner was satisfied that there was no need to look further into the surgeon’s practice as he had undergone training and a period of supervision in which no further incidents nor any poor surgical technique were identified. Read press coverage of the case here.
- Inquest into the death of James Frankish (2017)
Representing the care home in which the deceased lived at the time of his death. The deceased was a young man with severe autism, severe learning disability, and ‘Pica’ – a condition where individuals persistently eat non-nutritive substances. He died following having collapsed at the home as a result of oesophageal obstruction due to ingested plant material having eaten leaves form the home’s garden. The inquest examined the actions of the care professionals involved and the system in place for the assessment and management of risks in relation to the deceased’s conditions. The coroner returned a narrative conclusion finding that the staff caring for the deceased were caring and committed and that many aspects of his care were well managed but due to the rarity and generally misunderstood nature of Pica as a condition they did not fully appreciate his risky eating behaviours.
- Inquest into the death of Sarah Reed 
Representing the Central and North West London NHS Foundation Trust (“CNWL”) in an article 2 ECHR jury inquest into a self-inflicted death by self-strangulation by ligature of a prisoner on remand in Holloway Prison in January 2016. CNWL provided health services in the prison prior to its closure and various mental health nurses and psychiatrists had assessed Ms Reed during her 3 month stay at the prison, in particular on occasions when she appeared to have suffered a deterioration in her mental state with psychotic symptoms evident. The Coroner left a narrative conclusion to the jury who concluded that Ms Reed had taken her own life whilst the balance of her mind was disturbed to which the management of her anti-psychotic medication had contributed.
- Inquest into the death of Jonathan Palmer 
Representing the South London and Maudsley NHS Foundation Trust (“SLAM”) in an article 2 ECHR jury inquest into a self-inflicted death by hanging of a prisoner on remand in Wandsworth Prison in November 2015. SLAM provided mental health services in the prison and various mental health nurses and psychiatrists had assessed Mr Palmer during his 5 month stay at the prison, in particular on occasions when he appeared to have suffered a deterioration in his mental state with psychotic symptoms evident which may have related to his misusing new psychoactive substances. The Coroner left a narrative conclusion to the jury who concluded that Mr Palmer had committed suicide and that a significant contributory factor was the pressure of his impending trial. They also concluded that he had documented health problems of depression and chronic back pain which possibly contributed to his decision to kill himself. The jury made no criticisms of the SLAM clinicians’ actions.
- Inquest into the death of Michael Uriely 
Representing a Consultant Paediatrician in the inquest into the death of a nine year old boy who from asthma and pneumothorax. He had seen Michael privately on three occasions in the seven months prior to his death. Michael had a history of asthma which was poorly controlled and prone to periods of acute exacerbation. Despite being treated by an NHS and private GP, Consultant Paediatrician and having had a hospital admission shortly before his death he died following an acute deterioration in his condition. The inquest examined the actions of all the health professionals involved as to whether there was any contribution to the death as well as systemic aspects of the treatment of asthma in this case in the NHS and private sphere. The Coroner found that medication changes advised by the private Paediatrician in the months prior to the death were reasonable. A narrative conclusion recording that Michael was inadequately treated in his last hospital admission was recorded. The Coroner has written a “Prevention of Future Deaths” report to NICE.
Clicke here, here and here for press coverage
- Inquest into the death of Michael Bence-Lyons 
Acting for the NHS Hospital Trust in the inquest into the death of a 60 year old man from pulmonary embolism and deep vein thrombosis following surgery to repair a tendon in his knee. Mr Bence-Lyons had been discharged home without any compression stockings and with no continuing prescription for anti-coagulant medication. Whilst the Coroner found that he should have had compression stockings, there had been no indication for continuing medication as he was partially weight bearing on leaving the hospital. The Coroner therefore found that there was no basis for a finding of neglect against the hospital.
- Inquest into the death of Frankie White 
Representing the family of a premature baby who died at four days old from group B streptococcus (GBS) septicaemia. There had been a failure to appreciate risk factors for GBS which were present and as a result a failure to do a full sepsis screen and immediately administer intravenous antibiotics to Frankie at the appropriate time. The Coroner found that the delay in administering antibiotics led to the Frankie’s death and had they been given when they should have on the balance of probabilities he would have survived. The NHS Trust issued a formal apology to the family in respect of this failure in their care of Frankie.
- Sousse Inquests 
Acting on behalf of Metropolitan Police Service in pre-inquest hearings in relation to deaths of British tourists as a result of a terrorist attack at a holiday resort in Sousse, Tunisia (covering Claire Watson’s absence). The pre-inquest hearings were to deal with complicated matters of scope of the inquiry and disclosure to IP’s in these very high profile set of inquests due to be heard in 2017.
- Inquest into the death of Jack Susianta 
Representing the London Fire Brigade in inquest into the death of teenager due to drowning in canal following police pursuit in Hackney. The fire brigade are the service responsible for rescues in water and the coroner’s inquiry extended to their actions taken in attempting to find and rescue Jack, the co- operation between emergency services on the day and guidance, policies and training available to firefighters concerning water rescue.
- Inquest into death of Habib-Ullah 
Acting on behalf of Thames Valley Police in month long complex inquest into death in police custody due to restraint and ingestion of drugs. The coroner conducted an in depth inquiry into individual police officer’s actions in the restraint but also into the available guidance, policies and training to police officers from the force concerning restraint, searching of someone’s mouth and provision of first aid.
- In Amenas (2014)
Acting on behalf of Metropolitan Police Service in pre-inquest review hearings in relation to multiple deaths as a result of a terrorist attack on the In Amenas gas field in Algeria (covering Claire Watson’s absence). The pre-inquest hearings were to deal with complicated matters of scope of the inquiry and disclosure to IP’s in these very high profile set of inquests heard in 2015.
- Inquest into death of Leah Styles 
Representing private psychiatric hospital in Art. 2 jury inquest into death of detained psychiatric patient by hanging. In depth inquiry was undertaken into the assessment of risk and its appropriateness and the causal consequences of those assessments.
- Inquest into death of Linda McArthur 
Representing NHS Trust in inquest of patient due to a pulmonary embolus. Medical factual issues arose as to the extent of investigation and recognition of the PE and application of policies and guidance within this context.
- Inquest into the death of Santosh Muthiah Deceased 
Acting on behalf of the London Fire Brigade in inquest in relation to death of a man in a house fire caused by a fridge freezer. The Senior Coroner conducted an in depth inquiry into the knowledge of the relevant company as to the safety of its product at the relevant time. The LFB assisted with factual evidence of their dealings with the relevant bodies concerning histories of fires with these products and also with considerable technical expertise from the specialist fire investigators as to the particular causes of these fires.
- Inquest into death of John Hay 
Art 2 jury inquest into accidental drug related death of prisoner representing Prison GP. Complex issues arose as to standards of care in the prescription of methadone programmes on initial reception into prison and in relation to the mechanism of cause of death in this case.
- Inquest into the death of Martin Schroeder Deceased 
Acting on behalf of Metropolitan Police Service in Art. 2 inquest in relation to death of man in police detention as a result of sickle cell disease. This case involved complex causation evidence relating to the interplay between various factors in the death, including restraint by police officers. The Coroner praised police efforts in dealing with a deterioration in his medical condition and no criticism was made of any police action.
- Inquest into death of Malgorzata Doniec 
Acting for NHS Trust in maternal death as a result of dural puncture during epidural injection. The coroner investigated issues of individual actions of medical professionals as well as systemic issues which resulted in a delay in CT brain scanning. The issue of neglect arose and hypothetical issues of causation were particularly significant in this case where the initial puncture of the dura was not the subject of criticism.
- Inquest into death of Samantha Samson 
Acting for NHS Trust in inquest into 2 year old’s death due to multiple complex medical problems at Great Ormond Street Hospital.
- Inquest into death of Thi Hien Tran 
Inquest into death of prisoner on anti-coagulants from brain haemorrhage representing prison health care services. Difficult issues arose as to the standards of care to be expected within a prison setting and there was also some complicated expert medical evidence relating to cause of death.
- Inquest into death of Adrian Johnson 
Art 2 jury inquest into death of prisoner by hanging representing health care services in prison.
- Inquest into the death of Alina Sarag 
Inquest into death of a teenager related to tuberculosis representing a GP who saw her prior to her death. The medical evidence in this case was complex as the presentation of Ms Sarag’s TB was atypical and the causation of her death was complicated.
- 52 inquests into 7/7 London bombings 
Acting for the London Ambulance Service. This inquest comprised a wide-ranging inquiry into individual deaths, in particular the issue of survivability, whether those who were injured by the bomb blasts, but did not die immediately, could have been saved, perhaps by different or more timely action by the emergency services. Hallett LJ, sitting as coroner, came to conclusions that in all those cases where the person had succumbed to their injuries nothing could have been done to save them. Hallett LJ also made an in depth inquiry into the quality and nature of the emergency response generally with a view to making recommendations to prevent future deaths. http://7julyinquests.independent.gov.uk/
- Baha Mousa Public Inquiry 
Junior counsel acting for team of soldiers in this public inquiry into the death of an Iraqi detained by British troops. The group comprised 15 individual soldiers who were in conflict with other witnesses in the inquiry due to allegations of assault or mistreatment of detainees amounting to torture made against them or because they themselves had made such allegations against others. The group also comprised an army lawyer who had been alleged to have expressly sanctioned in legal advice the use of ‘stress positions’ on detainees and also an army medic who was alleged to have been complicit with others in mistreatment of detainees contrary to his medical duties.