Inquests in the News

IInquest Representation Servicenquests Reported in the Online Media

August 2014

10,000 more Deaths a year should be Investigated by Coroners, Says Royal College of Pathologists

July 2014

Inquest into Death from a Polar Bear Attack

Switched Off Street Lighting Contributed to Death, Inquest Verdict

May 2014

Inquest into Death of Peaches Geldof

January 2014

Inquest Verdict in Death of Mark Duggan

April 2016

Hillsborough Inquest. After 2 years of evidence the jury concluded the 96 Liverpool supporters who were crushed were unlawfully killed. This was the longest inquest in UK history.

June 2016

Birmingham Pub Bombings 1974. The Coroner re-opened the inquest on the basis it appeared there were 2 occasions when West Midlands Police missed opportunities to prevent the attacks.

July 2016

Robert Majchrzak Inquest.  The jury returned a narrative conclusion that the death (after setting a fire in his cell at HMP Wealstun) was the  result of the unintended consequences of his deliberate act, contributed to by the prison’s neglect.  The jury identified 7 gross failures, including failure to put suicide or self-harm protective measures in place.

March 2017

Inquest into the death of Milan Dokics.  Whilst riding his moped in the rain on 1 March 2017 Mr Dokics skidded on the blue paint used on London’s cycle superhighway and was in a fatal collision with a bollard. On 13 March 2017 the Westminster coroner stepped in to make a report to prevent future deaths seeking an urgent safety review of the blue paint. She concluded that the risk was so high that the case required such a report before the full hearing of the evidence took place.

Inquests into the Westminster Bridge Terror attack opened and adjourned.

June 2017

Manchester Arena Bombing. Separate inquests for the victims and the suicide bomber were opened and adjourned pending the completion of police investigations.

London Bridge Terror Attack. Inquests have been opened and adjourned pending the completion of police investigations.

Grenfell Tower Fire.  Inquests for 7 of the victims who have been identified so far following the tower block fire on 14 June 2017 have been opened and adjourned. Full inquests are very unlikely to take place until after the full public inquiry.

Camber Sands deaths. 30 June 2017, the coroner recorded conclusions of misadventure on the 5 young men who drowned at the Kent beach resort of Camber Sands in August 2016. The Coroner was unable to conclude whether the presence of lifeguards would have prevented the deaths.  Following a risk assessment in 2013 the RNLI had recommended the use of lifeguards on the beach. This had not been followed at the time of deaths in August 2016 but has since been implemented. Nevertheless the coroner identified matters of concern that triggered his duty to make a report to prevent future deaths.

July 2017

Alexander Perepilichnyy.  The inquest is taking place into this death in 2015 to consider whether he died of natural causes or unlawful killing as a  result of poisoning. Mr. Perepilichnyy was a known Russian whistleblower. The next hearing date for this inquest is 10 to 13 April 2018.

Edwin Lewis O’Donnell inquest into his death in custody. The jury returned a narrative conclusion of accidental death contributed to by neglect after Mr O’Donnell was found hanging in his segregation cell at Liverpool Prison. The evidence revealed significant errors in communication between staff and failure to escalate based on information received. For example, a request by a nurse that the deceased needed to be seen by mental health staff. The coroner was sufficiently concerned to make a report to prevent future deaths seeking action to remedy identified failures in communication and assessment processes.

Private Geoff Gray. The Attorney General has granted a fiat giving consent for the deceased’s family to apply to the High Court for a fresh inquest into his death. The coroner at the original inquest in March 2002 recorded an open verdict. Private Gray died from 2 bullet wounds to the head at Deepcut Barracks in Surrey in September 2001. The fiat has been granted on the basis that new material in now available.

Sarah Reed. Sarah Reed was mentally ill. She died in January 2016 at HMP Holloway after hanging herself. The jury returned a narrative conclusion that she had killed herself when the balance of her mind was disturbed, but were unsure whether she intended to do so. The jury identified that there had been serious shortcomings in her care that had contributed to her death. However since Sarah’s death the prison has closed.

August 2017

Anne Maguire. A High Court Judge ruled that the decision of the Assistant Coroner not to hear evidence from former students at the College in Leeds where Mrs Maguire was murdered by a fellow pupil at the forthcoming inquest in November was not seriously flawed.

January 2018

Poppi Worthington. At this second inquest into baby Poppi’s death, the Senior Coroner for Cumbria decided there was insufficient evidence to reach a conclusion of unlawful killing. He concluded Poppi had died of asphyxiation after being placed in an unsafe sleeping position sharing a bed with an adult. He decided that Poppi had been sexually assaulted before her death but it had not been a causative factor to the death itself. Whilst giving evidence Poppi’s father relied on the right to refuse to answer questions on the grounds of possible incrimination.

Stuart Lubbock. The Attorney-General has refused to issue a fiat under Section 13 Coroners Act 1988 to allow an application to be made to the High Court for a fresh inquest into the death of Stuart Lubbock. This was on the basis that there was no fresh evidence that would likely lead to a different conclusion being recorded if a fresh inquest was held. An open verdict was recorded at the original inquest in September 2002. In 2001 Stuart Lubbock was found dead in the swimming pool at the home of the entertainer Michael Barrymore.

24 January 2018

Dan Brandon. The cause of death was asphyxiation. Mr Brandon’s 8-foot pet python snake “Tiny” was found nearby. The coroner recorded a conclusion of misadventure.

26 February 2018

Ellie- May Clark. Having fallen ill at school the 5-year-old was turned away from an emergency appointment at her GP surgery because her mother exceeded the 10 minute rule and was told to return the next day. Ellie May had asthma which was known to be life threatening. She was found unconscious due to an asthma attack later that night and died. The coroner gave a narrative conclusion but did not go so far as to include a finding of neglect because she could not determine whether an earlier intervention would have altered the outcome. She was critical of failures in the GP practice system and disjointed care. The Gwent Coroner made a report to prevent future deaths.

18 July 2018

Private Sean Benton. Private Benton died of gunshot wounds at Deepcut army barracks in 1995. After a fresh inquest which had lasted since January 2018 the Coroner Judge Peter Rook QC reached a conclusion of suicide. The inquest had considered allegations of bullying of recruits, but this was not upheld in the coroner’s findings. Evidence was heard of changes that have been put in place by the army since 1995.

18 July 2018

Jereon Ensink. Dr Ensink was stabbed to death in Islington on his way to post letters. His assailant was suffering from psychosis and was later found guilty of manslaughter on the grounds of diminished responsibility. 7 months prior to the attack the assailant had been arrested by the Metropolitan Police for carrying a knife, but charges were dropped. The jury gave a narrative conclusion of unlawful killing. The jury concluded that there were a number of failings by the police in the arrest, custody and charging processes that resulted in possible mental health problems not being flagged up so the opportunity to treat was missed.

September 2018

Natasha Ednan- Laperouse

The 15-year-old died on 17 July 2016 due to a catastrophic anaphylactic shock. Natasha brought a baguette at the Pret a Manger at Heathrow T5 which contained sesame, an ingredient she was highly allergic to. Sesame was not listed as an ingredient on the food packing or on the food display fridge. Due to current food regulations non pre-packaged fresh food made on site does not require individual labels with allergen and ingredient information. Natasha collapsed during a BA flight to France. Her father administered 2 Epipens with 16mm needles. She suffered a cardiac arrest and later died in hospital. Dr Sean Cummings the Assistant Coroner for London (Western area) gave a narrative conclusion and made 3 Reports to Prevent Future Deaths;

  1. To Pret a Manger about collecting information of allergic reactions and responding to serious concerns;
  2. To Medicines and Healthcare Products Regulatory Agency (MHRA) and the manufacturers of Epipen about the apparently inadequate length of the needle and the dosage of adrenalin within the device;
  3. To Mr Michael Gove Secretary of State of the Department for the Environment, Food and Rural Affairs about whether large food business operators should benefit from the current regulation 5 of the Food Information Regulations.

October 2018

Westminster Terror Attack.

The Chief Coroner Mark Lucraft QC concluded 4 victims of the terror attack on 22 March 2017 were unlawfully killed by Khalid Masood when he drove his vehicle into them on Westminster Bridge. With reference to PC Palmer who was on duty at the gates to the Houses of Parliament, the Chief Coroner said “ due to the shortcomings in the security system at New Palace Yard, including the supervision of those engaged in such duties, the armed officers were not aware of the requirement to remain in close proximity to the gates. Had they been stationed there, it is possible that they may have been able to prevent PC Palmer suffering fatal injuries”. The Chief Coroner has yet to decide whether to make any Reports to Prevent Future Deaths.

November 2018

Jessica Whitchurch

Jessica was a vulnerable 31-year-old with a history of poor mental health, addiction problems and repeated episodes of self-harm. She was suffering from depression. She was a prisoner at HMP Eastwood but died in hospital in May 2016, 2 days after being found unconscious in her cell with ligatures round her neck. This came less than 2 hours after a previous incident when she had been found with ligatures around her neck. She was placed on suicide watch with half hourly observations. She was bullied by other inmates and was goaded to take her own life. In its conclusion the jury made a number of findings: The ACCT process after the first incident was deeply inadequate; a failure by prison officers to adequately communicate with each other and other healthcare staff after the first ligature incident; insufficient observation by prison officers during Jessica’s final hour in her cell; bullying and goading by other prisoners went unchallenged by staff; and, organisational failings in prison service staffing.

December 2018

Poppi Worthington

Poppi’s father Mr Paul Worthington has brought a judicial review of the inquest conducted by the Senior Cumbrian Coroner in December 2017. The claim seeks to challenge the fact that the inquest findings were not restricted to matters that caused Poppi’s death. The coroner made a finding that Poppi’s father had sexually assaulted his daughter before her death but that it had not caused the death. (The assault is denied). Mr Justice Hickenbottom has reserved judgment.


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