Davey, R (on the application of) v University Hospitals of Leicester NHS Trust & Anor

A coroner must first define the scope of the inquest before deciding whether circumstances trigger the duty to empanel a jury. Under section 8(3)(d) of the Coroners Act 1988, “reason to suspect” sets a low threshold, and the relevant section of the public need not be substantial. However, evidence of a recognised complication, adverse outcomes, or possible individual error does not, without more, establish a systemic failure or circumstances whose continuance or recurrence would prejudice public health or safety. The decision whether to empanel a jury remains for the coroner, subject to ordinary public law review. A later decision may be reconsidered if further evidence emerges.

The claimant challenged the coroner’s decision to hold an inquest into his mother’s death without a jury. She had died following a transcatheter aortic valve implantation procedure at Glenfield Hospital. The claimant alleged that the procedure involved a recognised complication and that similar deaths indicated a systemic failure.

The coroner concluded that there was no evidence of systemic failure and that section 8(3)(d) of the Coroners Act 1988 did not require a jury. The claimant pursued judicial review, contending that this conclusion was legally irrational.

1. The application was dismissed. The coroner had lawfully decided to conduct the inquest without a jury.
2. The applicable principles under section 8(3)(d) of the Coroners Act 1988 included the need first to identify the scope of the inquest, the low threshold represented by “reason to suspect”, and the requirement to consider whether the relevant circumstances involved a possible systemic failure. The relevant public section need not be substantial, and a causative link between those circumstances and the death was unnecessary.
3. The evidence before the coroner did not establish a proper suspicion of systemic failure. Cardiac tamponade was a recognised complication of the procedure, but the possible mechanisms included trauma, myocardial infarction, or an idiopathic cause. A recognised complication did not itself establish systemic failure or fault.
4. The evidence concerning other patients did not show that cardiac tamponade resulted from a guide wire or that any systemic defect was inherent in the procedure. There were no adverse regulatory reports or relevant learned literature establishing such a defect.
5. The coroner had considered the evidence and submissions and was entitled to conclude that section 8(3)(d) was not engaged. Her decision was not irrational or otherwise unlawful.
6. The coroner retained power to reconsider whether to empanel a jury if further evidence emerged. Any later decision would fall under section 7 of the Coroners and Justice Act 2009.

Permission to apply for judicial review was initially refused on the papers. His Honour Judge Robert Owen QC, sitting as a judge of the High Court, granted permission at an oral renewal hearing on 14 February 2014. The Administrative Court then dismissed the substantive application.