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Drilldown: Cases

Not many cases (259 of them) have been added to the database so far. To see the full list of cases (2085) go to the Mental health case law page.

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Cases > Subject : Inquests or Reporting restriction order cases

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Page name Sentence Summary
PW v Chelsea and Westminster Hospital NHS Foundation Trust (2018) EWCA Civ 1067

Best interests/transparency

"Two central criticisms are made of the judgment below, and the judge's determination of best interests. First, that the judge failed to appreciate and therefore give any or any adequate weight to RW's wishes and feeling. These were, contrary to her findings, ascertainable; they pointed to the fact that he was a "fighter", to the value he ascribed to life and to his desire to "hold fast to it" no matter how "poor" or "vestigial" in nature it was. Secondly, the judge overstated the risk that having the NG tube in place would pose for RW at home and the burden this would place on him, in circumstances where the dedicated care his sons could provide would remove or mitigate that risk. In the result, and in any event, it is submitted the judge's overall analysis of what was in RW's best interests failed adequately to address the relevant issues and evidence, and was a flawed one. In my view neither criticism is well-founded." Another aspect of this case related to the transparency order/reporting restrictions.

R (Lee) v HM Assistant Coroner for Sunderland (2019) EWHC 3227 (Admin)

Article 2 inquests and community patients

The coroner had decided that Article 2 was not engaged in this case, which involved the death of a community patient who was not subject to the MHA. (1) In relation to the operational duty, the coroner's decision had focussed almost exclusively on the question of responsibility rather than the "threefold factors of assumed responsibility, vulnerability and risk" set out in the Rabone case. The matter was remitted to the coroner for reconsideration. (2) The grounds which related to systemic failures were unarguable.

R (Maguire) v HM Senior Coroner for Blackpool and Fylde (2020) EWCA Civ 738

Inquest and DOLS

"The issue for determination in this appeal is whether the circumstances surrounding the death of Jacqueline Maguire (known as Jackie) required the coroner to allow the jury at her inquest to return an expanded conclusion in accordance with section 5(2) of the Coroners and Justice Act 2009. ... Jackie was subject to a standard authorisation granted by Blackpool Council pursuant to the Deprivation of Liberty Safeguards set out in Schedule A1 to the Mental Capacity Act 2005. ... Jackie's circumstances were not analogous with a psychiatric patient who is in hospital to guard against the risk of suicide. She was accommodated by United Response to provide a home in which she could be looked after by carers, because she was unable to look after herself and it was not possible for her to live with her family. She was not there for medical treatment. If she needed medical treatment it was sought, in the usual way, from the NHS. Her position would not have been different had she been able to continue to live with her family with social services input and been subject to an authorisation from the Court of Protection in respect of her deprivation of liberty whilst in their care."

R (Maguire) v HM's Senior Coroner for Blackpool and Fylde (2019) EWHC 1232 (Admin)

Inquest and DOLS

"First, the claimant contends that the defendant erred in law by determining at the end of the evidence that article 2 no longer applied under Parkinson, thereby prejudging a matter that should have been left to the jury. Secondly, the Coroner erred in law by determining that the jury should not be directed to consider whether neglect should form part of their conclusion. ... That the case law has extended the positive duty beyond the criminal justice context in Osman is not in doubt. The reach of the duty, beyond what Lord Dyson called the "paradigm example" of detention, is less easy to define. We have reached the conclusion, however, that the touchstone for state responsibility has remained constant: it is whether the circumstances of the case are such as to call a state to account: Rabone, para 19, citing Powell. In the absence of either systemic dysfunction arising from a regulatory failure or a relevant assumption of responsibility in a particular case, the state will not be held accountable under article 2. ... We agree that a person who lacks capacity to make certain decisions about his or her best interests - and who is therefore subject to DOLS under the 2005 Act - does not automatically fall to be treated in the same way as Lord Dyson's paradigm example. In our judgment, each case will turn on its facts. ... [The Coroner] properly directed himself as to the appropriate test to apply to the issue of neglect and having done so declined to leave the issue to the jury."

R (Maughan) v Her Majesty's Senior Coroner for Oxfordshire (2019) EWCA Civ 809

Suicide burden of proof at inquests

"This appeal involves questions of importance concerning the law and practice of coroners' inquests where an issue is raised as to whether the deceased died by suicide. The questions can be formulated as follows: (1) Is the standard of proof to be applied the criminal standard (satisfied so as to be sure) or the civil standard (satisfied that it is more probable than not) in deciding whether the deceased deliberately took his own life intending to kill himself? (2) Does the answer depend on whether the determination is expressed by way of short-form conclusion or by way of narrative conclusion? Those are the questions falling for decision in this case; but to an extent they have also required some consideration of the position with regard to unlawful killing. ... I conclude that, in cases of suicide, the standard of proof to be applied throughout at inquests, and including both short-form conclusions and narrative conclusions, is the civil standard of proof."

R (Silvera) v HM Senior Coroner for Oxfordshire (2017) EWHC 2499 (Admin)

JR of decision not to resume inquest

"In this claim for judicial review Muhammad Silvera challenges the decision of the Senior Coroner for Oxfordshire not to resume the inquest into the death of his mother, Ms Vittoria Baker. It is submitted that the decision of the Senior Coroner not to resume the inquest and thereby to hold a full inquest into this death was unlawful. It is submitted that the Senior Coroner breached the investigative duty under Article 2 of the European Convention on Human Rights and was irrational and in breach of the duty at common law to fully investigate this death. ... The Senior Coroner refers in his letter of February 2016 to the 'Crown Court Trial' together with the two reports as being sufficient to satisfy Article 2 of the Convention. There was, in fact, no Crown Court trial. At an early hearing an acceptable plea was tendered and 'K' was made the subject of a hospital order. The two other investigations comprised an internal NHS Trust investigation that was carried out in private and the DHR was expressed to be private and confidential. ... In all the circumstances, this claim for judicial review should be allowed."

Re Lee (2019) MHLO 73 (Coroner)

Article 2 inquests and community patients

The coroner, following the Administrative Court decision that she had failed properly to address the Article 2 operational duty as set out in the Rabone case, in this decision sets out reasons for concluding that (a) the operational duty was not neither engaged nor breached.

Re SW (2017) EWCOP 7

Medical treatment, costs, anonymity

(1) "[A]s matters stand, the transplant being proposed cannot proceed, whatever the court may say or do. As it has been presented to the court, this scarcely coherent application is totally without merit, it is misconceived and it is vexatious. It would be contrary to every principle of how litigation ought to be conducted in the Court of Protection, and every principle of proper case management, to allow this hopelessly defective application to proceed on the forlorn assumption that the son could somehow get his tackle in order and present a revised application which could somehow avoid the fate of its predecessor." (2) "As against the son, the claim for costs could not, in my judgment, be clearer. Given everything I have said, this is the plainest possible case for departing from the ordinary rule, set out in rule 157 of the Court of Protection Rules 2007, and applying the principles set out in rule 159. ... [B]oth Dr Waghorn and Dr Jooste, in my judgment, are persons against whom a costs order can be made even though are not, formally, parties to the litigation – and, if that is so, then for the same reasons as in relation to the son, it is, in my judgment, fair and just to order them to pay the costs." (3) "There is no reason why either SW or SAN should be named, and, indeed, every reason why they should not. Nor, in all the circumstances, is there any reason why the son should be named. Dr Waghorn and Dr Jooste, however, stand in a very different position. There is a very strong public interest in exposing the antics which these two struck-off doctors have got up to, not least so that others may be protected from their behaviour."

Rushbrooke v HM Coroner for West London (2020) EWHC 1612 (Admin)

Inquest determination and findings quashed

The applicant, who had been the deceased's Relevant Person's Representative under a DOLS authorisation successfully argued for the inquest's determination and findings to be quashed.

Southern Health NHS Foundation Trust v AB (2019) EWCOP 11

Injunction against publication of video

"This is an application to prevent publication of a video of a patient, AB, in her treating hospital. ... At times she is catatonic and lies in a foetal position on the floor. She has a history during these periods of self-harm, and for that reason she wears protective headgear at all times. In the light of AB's condition and the difficulties in accommodating her appropriately, the Trust has had to adapt the room in which she has been living urgently, and it is true to say that the condition of the room therefore looks somewhat poor. ... On about 20 January 2019, AB's son, W, who is the second respondent, took a video recording of his mother in her room. ... I am clear that it is appropriate in these circumstances to make the order. First of all, having seen the video, it is apparent that AB can be identified, even if pixilated, and would be identifiable from the information that Mail Online intend to publish. ... Secondly, it is clear from Dr Marlowe's statements that AB does not currently have capacity ... Thirdly, I have no doubt, having watched it, that the video would be an interference with AB's privacy and her private life. ... The draft order provides for W being able to apply to the court at a full hearing if he wishes to do so to seek to lift the injunction, and argue that it is in her interests to publish the video. Further, according to Dr Marlowe, AB may well regain capacity herself relatively shortly, i.e. within a matter of weeks, and if she then wishes for publication, that will be a matter for her."

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