Combe v HM Coroner for Blackburn, Hyndburn & Ribble Valley

Where a vulnerable patient dies in hospital after a possible fall, the circumstances should be subjected to a full and searching investigation. The investigation should address the cause of the fall, any failure to record it, precautions that might have prevented it, whether the pathologist knew of it, and whether injuries caused or contributed to the death. Where the original inquest did not investigate those material issues, the court may quash the inquisition and order a new inquest under Coroners Act 1988, section 13(1)(b).

The claimant, the former partner of William Tatters, applied with the leave of the Solicitor-General under section 13(1)(b) of the Coroners Act 1988. She sought to quash the inquisition and verdict of death by natural causes following an inquest into Mr Tatters’s death and to obtain a new inquest.

Mr Tatters had chronic obstructive pulmonary disease and died in hospital after developing serious respiratory difficulties. The evidence disclosed that he had apparently fallen from his bed about 12 hours before his death, sustaining a possible head injury, but the fall was not recorded in the clinical notes and had not been investigated at the inquest. The central issue was whether the original investigation was sufficiently thorough.

1. The application was allowed. The original inquisition and verdict were quashed, and a new inquest was ordered.

2. When a vulnerable patient dies in hospital after a fall, there should be a full examination of the circumstances. Relevant questions include whether the fall occurred, why it occurred, whether precautions such as bed rails could have reduced the risk, whether the pathologist was alerted, how thorough the post-mortem examination was, and whether injuries from the fall caused or contributed to death.

3. The court recognised that the coroner’s statutory functions might not permit formal findings on every subsidiary issue. The coroner must nevertheless undertake a thorough and searching investigation, obtain and consider the relevant material, and then hear and determine the issues as required by law.

4. The original inquest had not investigated the fall, the apparent omission from the clinical notes, possible precautions, or the relationship between any injuries and the death. That omission made it necessary to quash the original inquisition and direct a new inquest.

Prior procedural steps are not stated in the judgment. The application was determined by the High Court (Administrative Court), and the defendant coroner did not oppose it.