Seth Roberts Joseph Drysdale, R (on the application of) v His Majesty's Area Coroner for Greater Manchester (South)

An inquest must investigate matters capable of materially contributing to death, but it must not become a general review of clinical negligence. A coroner must disallow questions that cannot assist the jury in reaching a lawful conclusion. A finding of coronial neglect requires a gross failure to provide basic medical attention to a dependent person, together with a direct causal connection shown by evidence that the relevant care would probably have prevented or prolonged life. The Galbraith Plus test requires both evidence on which a properly directed jury could reach the proposed conclusion and a finding that it would be safe for the jury to do so. The court upheld the exclusion of questions concerning possible delayed diagnosis where the evidence established only a theoretical or possible lost opportunity.

The claimant sought judicial review of decisions made during an inquest into the death of his sister, who had been detained under section 3 of the Mental Health Act 1983 and had been prescribed clozapine. The inquest considered whether clozapine was connected with her myelodysplastic syndrome and acute myeloid leukaemia.

The claimant challenged the coroner’s refusal to permit two questions to a haematologist and the decision not to leave to the jury a conclusion that the death was from natural causes contributed to by neglect. He argued that abnormal blood results might have been misattributed to clozapine, delaying diagnosis and treatment. The central issues were whether the questions were relevant to the statutory purpose of the inquest and whether the evidence could safely support a finding of neglect.

1. The claim was dismissed. The two challenged questions concerned whether abnormal blood results might have reflected developing myelodysplastic syndrome rather than clozapine effects, and whether earlier investigation might have prolonged life. The coroner had to review the scope of the inquest as evidence emerged, but was also required to prevent questioning that could not support a lawful jury conclusion.
2. The statutory purpose of an inquest under section 5 of the Coroners and Justice Act 2009 does not permit a general review of the adequacy or reasonableness of clinical care. Section 10(2) prevents determinations appearing to determine civil liability. Rule 19(2) of the Coroners (Inquests) Rules 2013 required the coroner to disallow questions that were irrelevant.
3. Coronial neglect is a term of art. Under R (Jamieson), it requires a gross failure to provide basic medical attention to a dependent person. The failure must have directly contributed to death. The evidence must show a lost opportunity to provide care that would probably have been effective, rather than care that might have made a difference.
4. The Galbraith Plus test requires the coroner to ask whether a properly directed jury could properly reach the proposed conclusion and whether it would be safe for the jury to do so. Although the question whether conduct was gross ordinarily involves a value judgment for the jury, the issue should not be left where the evidence cannot support that conclusion.
5. The medical evidence showed, at most, that earlier diagnosis might theoretically have enabled different treatment. It did not show that earlier treatment would probably have prolonged life or produced a different outcome. A finding of neglect would therefore have been irrational and the questions could not assist the jury. No public law error had been established.
6. The court had no power to order a further Regulation 28 report in the absence of public law error, but encouraged the coroner to consider whether a report should address the risk that abnormal blood results in patients taking clozapine may be misunderstood.

First-instance judicial review in the Administrative Court. The court dismissed the challenge to the coroner’s decisions.