Duffy, R (on the application of) v HM Deputy Coroner for the County of Worcestershire & Anor

A coroner’s decision to refuse an adjournment is reviewable where it is wrong in principle or lacks a reasonable basis. Although successful challenges are rare, an adjournment is required where the available expert evidence is materially inadequate on issues central to causation, particularly where the expert lacks current experience in the relevant field and cannot assess a potentially contributory factor. The coroner must accurately evaluate the evidence and consider whether proceeding would risk substantial injustice. An inquest verdict reached after such a procedural failure may be quashed, with a fresh inquest ordered.

The claimant challenged an inquest into the death of his 14-month-old son. The deputy coroner returned a verdict of death from natural causes after hearing evidence from a pathologist and a paediatric cardiologist. The inquest was discontinued without hearing evidence from the treating doctors.

The claimant sought an adjournment so that evidence could be obtained from an expert with current experience in paediatric intensive care. The deputy coroner refused the application, concluded that the existing expert had answered the critical questions, and proceeded to verdict. The central issue was whether that refusal, and the resulting limitation of the inquiry, was legally sustainable.

1. Judicial review threshold. The court would interfere with a coroner’s decision on adjournment only where it was wrong in principle or had no reasonable basis in the circumstances. Successful challenges were rare, but that threshold was met here.
2. Inadequacy of expert evidence. The evidence raised serious questions about the medical care provided, including failure to recognise an enlarged heart, failure to correct severe metabolic acidosis, and the administration of substantial fluid boluses. The expert relied upon by the deputy coroner had not practised in paediatric intensive care for 15 years. His current experience was therefore lacking in an important respect.
3. Causation and fluids. The expert could not state whether proper treatment would probably have prevented death. He also accepted that excessive fluid could cause congestive heart failure, but could not advise whether the quantity administered was appropriate for a child of the relevant age and weight. Fluid management had already been identified as a possible contributory cause. The deputy coroner inaccurately and incompletely represented this evidence.
4. Disposition. The combination of the expert’s limited current expertise, the unresolved causation issue, and the inadequately examined fluid evidence meant that an adjournment was the only reasonable course. Proceeding created a real risk of substantial injustice. There was a material procedural irregularity. The verdict was quashed and a fresh inquest was required.
5. The court recognised that an adjournment would cause inconvenience and delay, but held that the interests of justice required it. It identified a wider argument concerning the scope of an inquest and possible neglect, relying on R(on the application of Takousis) v HM Coroner for Inner North London [2006] 1 WLR 461, R v North Humberside Coroner ex p Jamieson [1995] QB 1 and [1994] 3 WLR 82, and R v South London Coroner ex p Thompson [1982] 126 SJ 625. However, it considered it unnecessary to decide that wider ground.

The judgment was a first-instance judicial review of an inquest verdict. The deputy coroner had concluded the inquest after hearing two witnesses and returned a verdict of death from natural causes. The Administrative Court quashed that verdict and directed that a fresh inquest be held.