Inquests in the News
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.
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.
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.
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.
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.
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.
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.
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.
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;
- To Pret a Manger about collecting information of allergic reactions and responding to serious concerns;
- 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;
- 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.
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.
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.
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.
Marcie Tadman Inquest.
The coroner reached a conclusion of death by natural causes contributed to by neglect. The 2-year-old was taken to Royal United Hospital Bath in December 2017 with a high temperature, cough and vomiting. Staff failed to diagnose sepsis and she died of a cardiac arrest. The coroner found this was after a gross failure to provide to perform any effective medical treatment, and gross failures to follow proper or routine procedures and protocols including standard monitoring
The coroner concluded Mrs McAidee’s death was contributed to by the neglect of the pharmacist. Her GP had prescribed a drug to alleviate the pain from shingles. Instead the pharmacist dispensed a drug for high blood pressure. Mrs McAidee later fell into a coma and died.
Birmingham Pub Bombings.
The jury returned conclusions of unlawful killing.
In July 2014 Sussex police attended Mr Tomlin’s address. He struck a policeman so was restrained and subdued whilst he was arrested. He had been taking drugs and his partner thought he had suffered an epileptic fit. He stopped breathing whilst restrained in a prone position with his legs behind him and later died. The jury concluded that the cause of death was respiratory failure due to both the restraint in the prone position and the effect of the drugs. The death was contributed to by the neglect of the police.
Quyen Ngoc Nguyen
The coroner gave a conclusion of unlawful killing. Ms Nguyen had been raped and her body left in a burning car by two men who were each subject to life licence conditions after previous convictions for murder. The coroner was concerned about the lack of information sharing between the police and probation service that might have contributed to the death. He made a report to prevent future deaths to the justice secretary, chief constable of Northumberland Police and the probation service.
Miss Barden asphyxiated whilst performing sexually related role play for a man on-line. At the inquest the coroner concluded she had been unlawfully killed. The man had been under police investigation for the manslaughter of Hope but had died in prison whilst serving a sentence for having images of extreme pornography.
London Bridge Terror Attack
The Chief Coroner, HHJ Mark Lucraft QC recorded conclusions of unlawful killing with respect to the 8 people who died in the van and knife attack by 3 terrorists on 3 June 2017. In each case there was a short narrative explaining how they died. 48 others were injured. At the inquest the coroner looked in detail at many issues including the roles of the police and M15 and whether the attack could have been prevented, and non-erection of protective barriers on the bridge after the Westminster Bridge attack.
London Bridge Terror Attack
The Chief Coroner sat with a jury for the inquests into the deaths of the 3 terrorists who carried out the London Bridge attack. The jury concluded that the terrorists had been lawfully killed when shot dead by police who had shouted warnings before firing.
On 21 June 2017 temperatures recorded in London exceeded 30 degrees c. Mr Sochacki died in his cell at Westminster Magistrates Court of severe heatstroke and hypotensive heart disease after being found unresponsive mid-afternoon. Before arriving at court, he had been left in the cell of a prison services van for 50 minutes without air-conditioning. On arrival at court at 10 am he was put in an unventilated cell. Ineffective portable air-conditioners were being used because the court’s air-conditioning system was broken. The jury at the inquest concluded Mr Sochacki’s death was most likely due to him being subjected to excessive heat.
The Pontypridd coroner delivered a narrative conclusion with a finding of neglect. There had been a failure to provide basic medical attention. There were gross failings by the clinicians that contributed to the development of the deep veined thrombosis which was responsible for pulmonary thromboembolism that led to Mrs Roche’s cardiac arrest. Mrs Roche died during surgery to pin her broken thigh bone 12 days after she pulled out of the Cardiff half marathon due to a shooting pain in her leg. When she attended the Royal Glamorgan Hospital no x-ray was taken, and although she had a fractured femur it was diagnosed as a hamstring injury. X-rays were not procured on the next 2 occasions Mrs Roche attended the hospital even though she was in extreme pain and could not bear weight.
Manchester Arena Terror Attack
The inquest has been adjourned and is to be converted to a public inquiry so that the evidence from security service and counter-terrorism police can be heard in private in order to protect national security.
Corporal Joshua Hoole
A report to prevent future deaths was sent to the defence secretary due to continuing concerns about the army’s failure to safeguard army personnel training in high temperatures. This issue had been highlighted in an earlier inquest into the death of three soldiers from heat whilst on exercise. Cpl Hoole collapsed and died when an Annual Fitness test took place on the hottest day of 2016.
Douglas Oak suffered from acute behaviour disturbance (ABD). During an incident when he was behaving erratically in traffic he was restrained with handcuffs and leg straps by attending police officers. They recognised a medical emergency and requested a high priority ambulance. During the delay of over one hour before the ambulance arrived Douglas suffered a cardiac arrest contributed to by the restraint. He was admitted to hospital but later died. The senior coroner issued a report to prevent future deaths to the health secretary, the Policing Minister, and national policing and ambulance bodies. This was due to issues highlighted in the inquest evidence relating to the lack of training and guidance around ABD. It included a recommendation for the need for joint national guidelines on the management of ABD by the police and ambulance services.
Duncan Lawrence (Sophie Bennett inquest April 2019)
Duncan Lawrence refused to attend the inquest to give evidence. His case was the first criminal prosecution for withholding evidence/ documentation in relation to a coroner’s investigation. [See case summaries page]. He received a 4 month prison sentence. He had also been fined £650 by the coroner for his non-attendance.
An urgent judicial review application overturned the coroner’s ruling that 16 police officers could give evidence at the inquest from behind a screen where even the family would not be able to see them. R (on the application of Dyer) v HM Assistant Coroner for West Yorkshire (Western) [ see the case summaries page.]
St Michael’s Hospice, St Leonards, East Sussex
Three patients who were suffering from cancer died in a fire at the hospice on 11 July 2015. The fire had been started by another patient. Despite the cancer none of them would have died on that date. The senior coroner concluded they had been unlawfully killed. In criminal proceedings at the Crown Court the hospice pleaded guilty to fire safety breaches. The Senior Coroner did not hear any evidence at the inquest about the fire safety failures. He had ruled at a pre inquest hearing it was unnecessary because of the previous criminal case.
80-year-old Mr Lawler died after sustaining a fractured neck and spinal cord injury during treatment at a private chiropractic clinic in York. The coroner made a report to prevent future deaths directed to the General Chiropractic Council to address issues like compulsory first aid training for chiropractors, and a review of the requirements for pre- treatment imaging scans.
An inquest jury reached a conclusion of accidental death. On 9 May 2017 11-year-old Evha drowned after being thrown off the Splash Canyon River Rapids Ride at Drayton Manor Staffordshire. The coroner send a report to prevent future deaths to Drayton Park and several other theme park operators due to several matters of concern and to update on the extent all theme parks had acted upon the HSE Water Ride Safety Notice issued after Evha’s death.
Brighton and Sussex Hospitals Trust received a third report to prevent future deaths from the senior coroner (also sent to the health secretary and the Chief Executive of NHS England.) This was in the wake of another inquest involving an elderly patient being moved several times between hospitals. Jean Waghorn developed pneumonia and died in a case where she had been transferred between hospitals three times in 48 hours. The senior coroner was frustrated that despite issuing two previous reports to prevent future deaths on the issue of transfers of frail elderly patients the Trust was ignoring its own transfer policy.
The medical cause of death was starvation. Mr Graham who had mental health issues with a history of depression was found dead in his flat in June 2018 when bailiffs broke in to evict him.By then all his benefits had stopped from October 2017. He had not had contact with any agency since February 2018. The Assistant Coroner observed “The safety net that should surround vulnerable people like Errol in our society had holes within it”. The Department of Work and Pensions will undertake a serious case review.
Police were called as a result of Marc’s behaviour on the street. Prior to being taken into police detention Marc due to a mental health episode had self-harmed, had taken cocaine and was wandering around with a knife. He was tasered three times for about 43 seconds then handcuffed. He lost consciousness. Paramedics attended the scene and Marc suffered a cardiac arrest as he was being place in the ambulance. The jury found that the use of a taser by Devon and Cornwall police more than minimally contributed to the death as a result of going into cardiac arrest.
Miranda had been in police custody at Guildford Police Station since the early hours of 30 May 2015. She was suffering from the effects of drug and alcohol withdrawal. After referral to the local hospital A & E she was assessed as clinically stable and fit for detention and was discharged. On return to the cells at the police station she had a care plan of 30-minute welfare checks and medical reviews. Miranda had 2 checks by healthcare professionals in the early morning and around 5pm and had 30-minute custody checks. The CCTV showed an episode of hyperventilation with Miranda becoming still at around 7.24pm. This was identified as the probable time of death by the pathologist. The police continued with 30-minute custody checks using the spy hole rather than opening the cell door hatch. As a result, police officers incorrectly observed breathing and logged this. The inquest heard evidence that under the Authorised Professional Practice Guidance spyhole checks were insufficient as acceptable welfare checks. Miranda’s death was not discovered until the detention officer and a healthcare professional entered her cell at 7.15am on 31 May 2015. The jury found she died a sudden death during alcohol and drug withdrawal. Despite multiple welfare checks she remained in her cell for a further 12 hours.
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