Longfield Care Homes Ltd, R (on the application of) v HM Coroner for Blackburn & Ors

At an inquest, the Galbraith test governs whether evidence is sufficient to leave a verdict to the jury. The coroner also has a separate discretion, guided by the interests of justice, to withhold a technically available verdict where it would confuse or overburden the jury.

“Neglect” is a term of art. It requires a gross failure to provide essential care for a dependent person and a clear or direct causal connection with the death. A failure to carry out a risk assessment may constitute civil negligence but does not, without more, establish neglect at an inquest.

Where death involves natural disease and accidental injury, a narrative verdict may be required to describe how and in what circumstances death occurred.

Mrs Jessie Hall, a dementia sufferer resident at a care home, fell through an unattended window and sustained pelvic and elbow fractures. She died shortly afterwards from bronchopneumonia associated with dementia. The coroner left the jury verdicts including natural causes, accidental death, and accidental death to which neglect contributed. The jury returned the latter verdict.

The care home sought judicial review, arguing that the verdicts should not have been left, that the evidence was insufficient, and that the jury had been misdirected on neglect. The central issues were whether the evidence satisfied the applicable threshold, whether the coroner had discretion to leave the verdicts, and whether the inquisition accurately expressed the jury’s findings.

1. Evidence and discretion. The test in [1981] 2 All ER 1060, applied to inquests by [1999] 1 All ER 344, governed whether the evidence was sufficient to leave a verdict. If, taking the evidence at its highest, a properly directed jury could not properly reach the verdict, the coroner must withdraw it. If the evidence depends on matters within the jury’s province, the issue may be left to the jury. The test was satisfied because the jury could prefer the pathologist’s view that the fall might have accelerated death to the treating doctor’s view that it had not affected the disease process.
2. The coroner has a distinct legal discretion, in the interests of justice, not to leave a verdict even where the evidence is technically sufficient. That discretion is broad, but a decision to leave a verdict supported by sufficient evidence will rarely be successfully challenged on judicial review.
3. The direction on neglect was materially defective. Under [1995] QB 1, neglect requires a gross failure to provide adequate nourishment, liquid, basic medical attention, shelter or warmth for a dependent person, together with a clear or direct causal connection with death. The coroner wrongly centred the issue on the absence of a window risk assessment. That directed the jury towards civil negligence and may have led it to find neglect without applying the legal test.
4. The simple verdict of accidental death was also inadequate. The situation involved natural disease whose progression may have been accelerated by accidental injury. Following the general approach explained in [2004] 2 WLR 800, “how” death occurred includes the means and the circumstances in which it occurred. A narrative verdict was appropriate, while expressions implying civil or criminal liability had to be avoided.
5. The inquisition was quashed and amended by substituting a narrative verdict that Mrs Hall died of bronchopneumonia resulting from dementia, probably accelerated by the effect of her injuries on the pneumonia. A fresh inquest was unnecessary. No order was made as to costs because the parties had each substantially succeeded on different issues and the costs could not fairly be disentangled.

First-instance judicial review in the Administrative Court. The judgment itself refers to the prior authorities but does not state any appellate history for this claim.