Davies, R (on the application of) v HM Deputy Coroner for Birmingham & Anor

A coroner must explain that neglect may arise from a gross failure to provide basic medical attention, even where an individual has made a clinical assessment and taken some action. A clinical decision is not immune from assessment as possible neglect. An inquest may also need to address systemic defects in the care of a dependent person. The concept of neglect must not be diluted by describing the verdict as rare. A verdict need not be quashed where the inquest was otherwise full, the relevant evidence was investigated, and further practical benefit from a fresh inquest is unlikely.

The claimant, the mother of a prisoner who died from dehydration in custody, challenged the deputy coroner’s conduct of the inquest. She alleged that the jury had been misdirected on neglect, that the possible failure of a nurse to seek medical assistance had not been properly left to the jury, that systemic deficiencies in the treatment and follow-up of prisoners withdrawing from drugs had not been considered, and that relevant expert evidence had been excluded.

The jury had returned a verdict of accidental death. The central issues were whether the directions misstated the scope of neglect and whether the defects justified quashing the verdict or ordering a fresh inquest.

1. Clinical judgment and neglect. The test in R v HM Coroner for North Humberside and Scunthorpe, ex parte Jamieson [1994] QB 1 remained applicable. A gross failure to provide basic medical attention may exist even where an individual has attended, formed a clinical view and taken some action. The question is whether the conduct amounted to a gross failure in the circumstances, not whether no action was taken.
2. The deputy coroner’s directions were unclear. They appeared at some points to suggest that the jury could not find neglect where Nurse Spencer had exercised clinical judgment, while elsewhere suggesting that such a finding was possible. The jury should have been told clearly that the failure to seek assistance was capable of constituting neglect, although the ultimate verdict would depend on the evidence.
3. System neglect. The reasoning in R (Amin and Middleton) v Home Secretary [2002] 3 WLR 505 established that a verdict of system neglect may identify defects in arrangements which contributed to death and may help prevent recurrence. The inquest should have left to the jury the issue whether the system for following up prisoners requiring medication for drug withdrawal was defective and whether that defect constituted neglect.
4. The coroner was entitled to exclude the final aspects of Dr Ralli’s evidence. His report did not state that the death was preventable by steps which any reasonably competent doctor would have taken. The position therefore differed from R (Nicholls) v Coroner for the City of Liverpool [2001] EWHC Admin 922.
5. The comments describing neglect verdicts as rare were unhelpful and wrong insofar as they purported to define neglect. The rarity discussion in R v Portsmouth Coroner, ex parte Anderson [1987] 1 WLR 1640 concerned the distinct and logically difficult notion of an accidental death aggravated by neglect.
6. Despite the misdirections, the court declined to quash the verdict or order a fresh inquest. The investigation had been full, substantial evidence concerning both individual conduct and the system had been heard, and the coroner had made recommendations for improvement. No further relief was sought.

First-instance judicial review in the Administrative Court. The court identified material deficiencies in the coroner’s directions but declined to quash the verdict or order a fresh inquest.