Mays & Anor v HM Senior Coroner for Kingston Upon Hull & East Riding of Yorkshire  EWHC 3604 (Admin) (01 December 2021)
We have now received the Approved Judgement of the High Court Order issued on 1 December 2021 quashing Sally’s original inquest and ordering a fresh one be heard.
Some points of note from the ruling are as follows:
3. On 25 July 2014 Sally was refused admission to a psychiatric inpatient facility at Miranda House. The medical cause of her death was mechanical asphyxia in combination with an overdose of Codeine and Nitrazepam. The Senior Coroner found that the failure to admit Sally to an acute inpatient psychiatric bed constituted neglect which had a direct causal relationship to her death later that evening.
4. Shortly after the inquest concluded it came to light that information relevant to how Sally came by her death had been withheld from the NHS Trust internal investigation and, more importantly, the Senior Coroner’s inquest. That information was also not shared with the claimants.
10. The Senior Coroner was also critical of the manner in which the NHS Trust responded to requests for information, disclosure of documentation and, more broadly, in its dealings with the Mays’ family.
12. As already indicated, following the conclusion of the inquest on 23 October 2015, it was discovered that certain information had been withheld during the inquest. The information came to light as a result of a note produced by Debbie Barratt, Assistant Director of the NHS Trust, dated 27 October 2015. That note reads as follows:
“I had a conversation yesterday morning at about 9.15 a.m. with Laura Elliot, staff nurse, who has been working with me for a few weeks during the inquest of SM, in an attempt to keep her in work whilst the process is ongoing. During the conversation Laura was reflecting on the inquest and said that she had learnt the importance of documenting everything as a result. Laura went on to say that she had had a conversation with Dr Fofie in the car park at Miranda House as she was leaving on 25th July 2014, after the assessment with SM and the two members of staff from the Crisis Team. Laura said that she was upset and that Dr Fofie asked her what was wrong. Laura explained what had happened to Dr Fofie, who told her that everything would be all right, that SM would settle down or be picked up by a service.
Laura said that she had not documented this conversation and that she had had a conversation with Dr Harkness about this some months later and they had felt that it would look like they were not being helpful by bringing new information to light at that late stage. I told Laura that this was new information to me.”
20. The examiner’s decision also records the fact that Dr Harkness:
“told the police that the CPN spoke to him during the inquest about the fact that she had been questioned closely at the inquest about why she did not escalate her concerns about the decision not to admit Ms Mays.
. . . However, Dr H told the CPN it may be helpful to her to disclose the discussion with Dr Opoku-Fofie, as this would demonstrate that she had at least mentioned the matter to a consultant and they did not react with great concern. Dr H said the CPN gave the impression, in response, that the conversation had not been of any clinical relevance.”
It is clear from these documents that both Consultants, who knew Sally and had previous responsibility for her, took conscious decisions, both before and during the inquest, to withhold information about that car park conversation. The professional regulatory investigations were closed in January 2020 and July 2020 respectively, without any disciplinary action being taken but, more significantly for present purposes, without establishing the facts relating to the conversation in the car park.
36. The wishes of Sally’s parents are also relevant, as the authorities make clear, in determining whether the ordering of a fresh inquest is desirable. They must, of course, be weighed with other factors including the resources and time required to hold the fresh inquest. But as Popplewell LJ observed in Farrell (referred to above) justice must not only be done but must be seen to be done, and family members must be given meaningful opportunities to make sense of the circumstances that led to the death of their loved-one. In this case, it is through no fault of the claimants that neither Ms Elliot nor Dr Fofie gave the evidence about the discussion in the car park. This came to light only after the inquest and that must have been both frustrating and distressing to them. It has, I imagine, prevented them from obtaining the closure they sought regarding their daughter’s death at the earliest opportunity and has, no doubt, prolonged their grief. In these circumstances too I consider it to be desirable for a fresh inquest to be ordered.
40. In conclusion, for the reasons I have given, this is a case where the criteria in section 13 are satisfied. It is both necessary and desirable in the interests of justice to quash the inquest and to order a fresh inquest in order for the new evidence concerning the conversation in the car park to be investigated and for the facts in relation to that to be established. Article 2 produces the same result, and if my Lady and my Lord agree, that is the order I would make.