Parkinson, R (On the Application Of) v HM Senior Coroner for Kent

In medical-death cases, the enhanced investigative duty under Article 2 arises only where there is an arguable breach of the State’s own substantive obligation to protect life. Ordinary medical negligence, including an individual error of judgment or negligent co-ordination, is insufficient where adequate professional and regulatory systems exist. Exceptional cases may arise where emergency treatment is denied despite awareness of the risk to life, or where systemic or structural dysfunction deprives a patient of life-saving treatment.

A Prevention of Future Death report under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 requires the coroner to have the specified concern and opinion. Findings of fact in judicial review proceedings are subject to an exceptionally demanding rationality threshold.

The claimant challenged the Senior Coroner’s inquest into his mother’s death at Darent Valley Hospital. He argued that the coroner had failed to conduct an Article 2-compliant investigation, had irrationally determined the medical cause of death and related facts, had used an insufficient short-form conclusion, and had failed to make a Prevention of Future Death report.

The central issues were whether the evidence disclosed a systemic failure engaging Article 2 and section 5(2) of the Coroners and Justice Act 2009, whether the findings were irrational, and whether paragraph 7 of Schedule 5 imposed a reporting duty.

1. Claim dismissed. The Divisional Court held that the enhanced investigative duty under Article 2 is parasitic on an arguable breach of the State’s substantive duty to protect life. In medical cases, the distinction is between systemic or structural failure and ordinary individual negligence. The Court followed the authoritative clarification in Lopes de Sousa Fernandes v Portugal (app. no. 56080/13) and considered it consistent with domestic authority.
2. The hospital had relevant triage and resuscitation policies. The evidence entitled the Senior Coroner to find that staff understood the distinction between the Manchester Triage System and the Patient At Risk score, that the Medical Emergency Team was not ordinarily called to A&E, and that there was no systemic failure. No arguable breach of Article 2 therefore arose, so no enhanced investigation was required.
3. Paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 required both a relevant concern arising from the investigation and the coroner’s opinion that preventive action should be taken. The Senior Coroner reasonably concluded that neither condition existed.
4. Challenges to factual findings by a coroner required the claimant to show that no reasonable coroner could have reached them. The Court upheld the findings that bronchopneumonia was the probable cause of death, that further treatment would not have changed the outcome, and that the claimant’s conduct obstructed a full examination. The Senior Coroner was entitled to prefer Professor Sheppard’s evidence.
5. The formulation of the record, including the reference to possible pulmonary thrombi, was unobjectionable because the probable cause was clear. The precise time of death was irrelevant to the conclusions reached. The claim was dismissed on all grounds. Costs were awarded to the defendant and both interested parties, subject to detailed assessment if not agreed.

The judgment describes the claim as an application for judicial review. Permission was granted by Mostyn J. The Divisional Court dismissed the claim on all grounds.