In the recent case of R (on the application of Carol Mack) v HM Coroner for Birmingham & Solihull (2011), the inquest into the death of an elderly gentleman was quashed because the coroner had failed to call as a witness the gastroenterologist who was responsible for the patient for the ten days before his death.

The deceased developed clostridium difficile following a hip operation. He was initially cared for in the intensive care unit under the care of an endocrinologist but was then moved to the clostridium difficile ward under the care of a gastroenterologist. Ten days later he suffered a cardiac arrest and died.  

The hospital concerned sent the endocrinologist to the inquest but not the gastroenterologist.

There were considerable issues raised by the family arising from the deceased’s time spent on the clostridium difficile ward. These included the failure to administer drugs due to unavailability of the drug, defects in recording his fluid levels, blood tests taken but not reviewed by a doctor and failure to carry out the further tests ordered by the gastroenterologist. The family argued that these were evidence of systematic failures.

The endocrinologist was unable to answer the questions relating to the apparent systemic failures on the clostridium difficile ward. Despite the issues raised by the family, the coroner did not call the gastroenterologist to give evidence.

The court determined that this was unreasonable and ordered a fresh inquest.

This case highlights the importance for trusts of highlighting issues before an inquest and ensuring that staff are available at the inquest who can address these issues adequately.