Wilson v HM Senior Coroner for Birmingham And Solihull

An inquest is an inquisitorial investigation, not adversarial civil or criminal litigation. Fairness must therefore be assessed in that procedural setting. Interested persons have no pleaded case, and the evidence may develop unexpectedly. The coroner determines the proper scope of the inquiry and need not investigate every underlying record where the issue can fairly be addressed at a more general level. A serious adverse implication may be made only where the person concerned had a meaningful opportunity to respond. A conclusion will not be irrational merely because evidence comes from a non-independent or non-expert witness, particularly where the underlying analysis has not been substantively challenged.

The claimant, a consultant cardiothoracic surgeon, sought judicial review of narrative conclusions recorded by the Senior Coroner following inquests into the deaths of three patients. Each conclusion stated that historic inaccurate recording of post-operative data had caused a missed opportunity to identify potential problems earlier, which might have resulted in the operation being undertaken by a different surgeon.

The claimant argued that the coroner acted unfairly by relying on evidence about inaccurate recording of pre-operative risk data without disclosing all underlying medical records; failed adequately to investigate the issue; and reached an irrational conclusion. The central question was whether the coroner’s procedure and conclusion involved public law error.

1. Claim dismissed. The claim for judicial review was dismissed.
2. An inquest under Coroners and Justice Act 2009 is an inquisitorial fact-finding investigation into how, when and where the deceased came by his death. It is not comparable to a criminal trial or civil proceedings. There are no parties, pleadings, prosecution or defence, and the ordinary rules of evidence do not apply.
3. Fairness must be assessed in that context. Interested persons do not have a pleaded case, and evidence may take an unexpected turn. It is for the coroner to determine the bounds of the inquiry and to decide the level of investigation required.
4. The claimant had adequate notice of the evidence that inaccurate recording of angina and pulmonary hypertension data might have triggered an earlier alert and intervention. He could have challenged the analyses generally, explained why the figures were wrong, sought further questioning of the witness, or been recalled to give evidence. He chose not to do so. The coroner was entitled to conclude that investigating the individual medical and prescription records of more than 80 patients was unnecessary.
5. The sentence in the narrative conclusions pointed to the claimant as the surgeon who might not have performed the operations, but did not identify him as the person who had recorded the inaccurate data. The coroner was entitled to reach the conclusion on the evidence before her. It was not irrational.
6. The witness’s involvement in reporting the concerns and in the disciplinary process did not require his evidence to be discounted. His lack of expertise might justify caution because part of his evidence was hearsay, but no substantive basis for challenging the underlying analysis had been advanced.

The judgment concerns a first-instance judicial review challenge to conclusions reached at three coroner’s inquests. No earlier judicial decision is stated.