Lewis, R (on the application of) v Coroner for North West Kent

In an inquest concerning a state-detained patient who died of malnutrition, neglect must be left to the jury where the evidence gives rise to a properly arguable finding of a gross failure to provide adequate nourishment or basic medical attention, with a clear causal connection to the death. Neglect is a term of art in coronial law and must not be equated with negligence. A coroner cannot withdraw the issue merely by making an unexplained decision based on the Jamieson and [1995] QB 1 principles. The failure to leave neglect in such circumstances renders the inquest flawed and may justify quashing the jury’s conclusion and ordering a fresh inquest.

The claimant, the sister of Jennifer Lewis, sought judicial review of the jury’s conclusion at an inquest into her death. Ms Lewis had been detained in a psychiatric unit and died after severe malnutrition and physical decline. The family contended that the evidence disclosed neglect, including failures concerning nutrition, hydration, monitoring and medical care.

The coroner left questions concerning the care provided to the jury but did not leave neglect as an available finding. The central issue was whether, applying the Galbraith principles and the guidance derived from R v Her Majesty’s Coroner for North Humberside and Scunthorpe, ex parte Jameson and [1995] QB 1, neglect was properly open on the evidence.

1. Neglect as a coronial finding. Under section 10(2)(b) of the Coroners and Justice Act 2009, a jury cannot frame its determination so as to appear to determine civil liability. Nevertheless, neglect remains available in an appropriate case. It is a term of art, distinct from the tort of negligence, as explained in R (Middleton) v West Somerset Coroner, [2004] UKHL 10 and [2004] 2 AC 182.
2. Threshold for leaving neglect. Under Jameson, neglect involves a gross failure to provide adequate nourishment or liquid, or to provide or procure basic medical attention, for a dependent person unable to provide it personally. A clear and direct causal connection with the death is required. The issue is highly fact-sensitive and must not be used to criticise every aspect of complex medical treatment.
3. Application. The evidence disclosed pronounced weight loss, physical manifestations of malnutrition, inadequate records, apparent non-compliance with the institution’s nutrition and hydration policy, and failures concerning monitoring and medical advice. In the context of a person detained under state authority who died of malnutrition, a finding of neglect was properly open to the jury. The coroner was not reasonably entitled to withdraw that issue.
4. Reasons and disposal. The coroner should have given a reasoned ruling when declining to leave neglect. The court could not itself make a finding of neglect, since that was for the jury. The jury’s conclusion was quashed and a new inquest ordered, preferably before a different coroner.

The proceedings were a first-instance judicial review of the conclusion reached by the jury at the inquest before the Senior Coroner for North West Kent. The Administrative Court quashed that conclusion and ordered a new inquest.