Summary

A recent High Court judgment is a helpful reminder that if new evidence comes to light after an inquest has concluded, the original inquest may be quashed and a new inquest ordered if it is necessary or desirable in the interests of justice. 

The facts

Two patients died at the Royal Cornwall Hospital (“the hospital”) after undergoing abdominal surgery. Both deaths were separately referred to the Coroner who returned narrative conclusions indicating both patients had died due to recognised complications of surgical procedures.

New evidence

In January 2019, the hospital invited the Royal College of Surgeons to carry out a review of the Unit’s systems and the work carried out by a particular surgeon. The review identified “serious patient safety issues” concerning the patients of the surgeon as well as the need to improve multi-disciplinary processes at the hospital. In particular, the review found potential lapses in care in relation to both patients regarding the consent process and the quality of the surgical procedure.

The findings of the review therefore called into question (i) the medical cause of death recorded at the inquests and, (ii) the validity of the findings of fact as the review raised the possibility that the surgeon’s acts or omissions may have contributed to the deaths. 

The law

The Coroner made an application to the High Court, pursuant to Section 13 of The Coroner’s Act 1988 (“the 1988 Act”) seeking an order to quash the original inquest conclusion and order a fresh investigation. 

In considering whether it was ‘necessary or desirable in the interests of justice’ to order a new inquest, the Court was reminded of the approach taken in relation to the Hillsborough inquests. In that case, it was recognised that where the emergence of fresh evidence may reasonably lead to the conclusion that how an individual met their death had not been revealed at the original inquest, it would normally make it both desirable and in the interests of justice for a new inquest to be ordered. 

The Decision

Adopting this approach, the Court found that the Coroner at the inquests through “…no fault if his own” conducted the proceedings with “…an incomplete picture of the circumstances of the death”. Although the Court was reminded it was not necessary for the Coroner to show it was probable that a new inquest would lead to different factual findings, the Court found “…it seems likely that the findings recorded at a fresh investigation would in each case differ”.

The Court determined that in light of the new evidence, it was “in the public interest” and “both necessary and desirable in the interests of justice that another investigation” be held.

Article written by Emma Maguire and Jordan Coulton