Coroner overruled: time for reform?

Abstract

As pressure mounts for a change in the way coroners' inquests are conducted more challenges to inquest verdicts are reaching the high court. Last month, quashing the jury's verdict in an inquest described by Mr Justice Peter Pain as liopelessly flawed, the court recognised of as a possible verdict in appropriate cases and clarified the ambit of the verdict in cases in which medical care is an issue.1 The case concerned a 38 year old epileptic and schizophrenic, Keith Hicks, who was detained in Brixton Prison after an assault on his father while suffering paranoid delusions. On 1 March 1985 he was convicted of assault, and a hospital order was made by the court, ordering his detention under section 37 of the Mental Health Act 1983, but he died in Brixton Prison on 12 March, the day he was due to be transferred to hospital. The cause of death given on the necropsy report was status epilepticus. The Hicks family was concerned about the quality of medical care Keith had received in prison. On 10 January 1985 he had been admitted as an emergency to the Maudsley Hospital. Ten days later he was returned to Brixton, where the treatment started in hospital?phenytoin?was continued. For some days before his death he was His mother was told that he had had petit mal fits and was not allowed to see him on 6 March. On 7 and 8 March she was again told he was not well. His sister was given the same information on 9, 10, and 11 March. On 11 March he had a grand mal seizure and was put to bed. At necropsy the whole blood phenytoin concentration was 3 mg/1, equivalent to a plasma concentration of 5 mg/1. The question was raised whether that figure indicated that he had not been receiving the proper dose, and the family wanted to know what care he had received between 6 and 12 March. The inquest, at Southwark Coroner's Court, was presided over by a deputy coroner, Dr David Foster. Before the inquest, and again during the proceedings, lawyers for the family asked for Keith's prison medical records and copies of statements by the hospital and prison staff and those who had treated Keith during his stay in prison. Dr Foster refused the request. The coroner called a prison doctor as a witness, believing that he would be able to give evidence about all the treatment Keith had been given in prison and about the contents of the notes that he had brought to court. As it happened, he had not seen Keith after 6 March, though other doctors had. Counsel for the family wanted to find out which other doctors had seen Keith after 5 March so that they might be called as witnesses. He told the coroner: I do formally apply that this is the crux of the case, to discover what was wrong with this deceased person over the five days before his death, and that we must, if we are to find out, have evidence either in documentary or oral form about why his family were being told that he was so unwell. The application was disallowed, and, though it was put forward several times, it was refused each time. At the end of the evidence counsel applied to address the coroner, to submit that the verdict of lack of care should be left to the jury. The coroner refused the application (which he conceded to the high court he was wrong to do, though he believed it was an inappropriate verdict) and left a choice of natural causes, accident, misadventure,* and an open verdict. The jury brought in a verdict of misadventure.