A recent hospital death inquest was quashed in circumstances where the Coroner was unable to provide a rational explanation for not calling a particular treating clinician to give evidence.

M developed a clostridium difficile infection after a routine hip operation. He was initially treated in intensive care by a Consultant Endocrinologist (Y) and his team. He was then moved to a clostridium difficile ward, where he was under the care of a Consultant Gastroenterologist (P). After 10 days on P’s ward, M suffered a cardiac arrest and died.  

M’s family provided the Coroner with an extensive list of clinical witnesses who they wanted to be called to give evidence to the inquest, as they considered that the treatment M had received was indicative of systemic failures. The Coroner dismissed M’s family’s list and only asked Consultant Y to give evidence. On the basis of the evidence heard, the Coroner found that although there had been shortcomings in M’s hospital care, the shortcomings did not amount to neglect. The Coroner therefore concluded that M had died of natural causes.

The question as to who should have given evidence at the inquest fell to the Court of Appeal. It was held that in this case, the 10 days M spent on P’s ward gave rise to considerable concerns which appeared to be a series of errors rather than one individual’s failings (for example drugs not being available, blood tests not being carried out). In these circumstances, the Coroner had not adequately explained why Consultant Y had been called to give evidence rather than Consultant P, who would have been the more natural choice. The court rejected the Coroner’s explanation that he had followed the hospital’s choice of which clinician to send to the inquest as not being rational and they ordered a fresh inquest should take place before a different Coroner.  

The decision reiterates that the Coroner’s role is to consider the full clinical history and it is for him to decide which witnesses to call. Each case will turn on its facts, but it is clear that all Properly Interested Persons should carefully consider which of their witnesses are best placed to assist the Coroner.

R. (on the application of Mack) v HM Coroner for Birmingham & Solihull (2011)(AC9101098)