When does fresh evidence require a further inquest under s.13 of the Senior Coroners Act 1988?

HM Senior Coroner for Cornwall and the Scilly Isles v Elaine Rowe, Helen Price, Royal Cornwall Hospitals NHS Trust [2024] EWHC 2673 (Admin)

Facts

Before Lord Justice Holroyde and Mrs Justice McGowan, HM Senior Coroner for Cornwall and the Scilly Isles applied for orders quashing the two inquests into the death of Edward John Masters and Mary Helen Rooker, held in 2017 and 2013 respectively. The application was made pursuant to Section 13(1)(b) of the Senior Coroners Act 1988 on the ground that new facts and evidence made it necessary and desirable for a fresh investigation into the deaths. All of the interested parties were aware of, and supported, the applications.

Mr Masters underwent elective surgery in 2017 to repair an abdominal aortic aneurysm. After initial recovery from surgery, his condition deteriorated and he suffered internal bleeding leading to cardiac arrest. He sadly died later that evening. The original inquest into Mr Masters death concluded that he had died from a known complication of the elective surgical procedure.

Mrs Rooker also underwent surgery for the repair of an abdominal aortic aneurysm in 2012. Post-operatively, she suffered internal bleeding. A laparotomy could not identify an obvious cause of the bleeding, and she underwent a further procedure when a scan revealed a perforation of the bowel. Her condition continued to decline over the following days and she sadly died 12 days after the initial surgery. The original inquest concluded that Mrs Rooker’s death was partly caused by peritonitis, a recognised complication of the surgery.

Fresh Evidence

In January 2019, Royal Cornwall Hospitals NHS Trust requested the Royal College of Surgeons to undertake a review of their vascular surgery unit, including the work of the surgeon who had operated on Mr Masters’ and Mrs Rooker. Serious patient safety issues in relation to the patients of that surgeon were identified by those conducting the review.

The fresh evidence identified shortcomings in the consent process and in the care and treatment of Mr Masters during his operation.

An expert report, not available at the time of the original inquest, by Professor Bradbury (a Professor of Vascular Surgery and Consultant Vascular and Endovascular surgeon), pointed towards negligence in relation to Mrs Rooker’s surgery on three parts: (i) proceeding to operate despite low platelet count; (ii) lack of informed consent; and (iii) unacceptable standards of treatment.

In both cases, the evidence raised the possibility that their deaths were contributed to by acts/omissions on the part of the surgeon and by a collective failure of care and systems at the hospital.

Legal test

In these circumstances, the Court was required to consider the single question as to whether the interests of justice made a further inquest either necessary or desirable.

In doing so, they applied the Hillsborough case (HM Attorney General v HM Coroner of South Yorkshire (West) [2012] EWHC 3783) where the  Lord Judge CJ had stated “…it seems to us elementary that the emergence of fresh evidence which may reasonably lead to the conclusion that the substantial truth about how an individual met his death was not revealed at the first inquest, will normally make it both desirable and necessary in the interests of justice for a fresh inquest to be ordered.”

Findings

The Court was satisfied, on the fresh evidence before it, that it was necessary and desirable in the interests of justice for another inquest to be directed in both cases. The determination and findings of the original inquests were quashed. The Court noted it was not necessary for the Coroner to prove that a fresh investigation would probably lead to a different outcome, but on the evidence before them in each case, it was considered likely in any event.

The judgment can be found here.