Inquests & Inquiries
Pravin’s previous experience of mental health care has proved valuable in Article 2 cases involving suicides in institutional settings. He also has unrivalled experience in paediatric death (see notable cases below). He has a fantastic knowledge of the practical issues facing institutional clients and is available to advise at any stage during the inquest process.
Deaths Concerning State Contact
PM – death following police contact in a hospital. The deceased was reported to be acting in an aggressive manner by hospital staff who called the police. The inquest over many weeks concerned communication between hospital and police, assessment of risks, use of force and restraint techniques.
BH – death concerning suicide in prison custody following a suspected murder by the deceased. The inquest concerned issues such as the identification of self-harm, observations, medication regime, suicide and communication between agencies.
NR – death of a young woman detained under section 2 of the Mental Health Act 1983. The inquest concerned the prescribing of psychotropic medications and their side effects, observations, access to community medical records, the use of bank and agency staff, handover and life support training.
AH – death concerning suicide in prison custody and the provision of mental health services, the use of camera cells, opening of an ACCT, level of observations, the adequacy of medical assessments.
AD – death in an Immigration Removal Centre concerning an 85-year-old man in a confused state arriving in London having boarded a flight from Vancouver, Canada. The inquest involved multiple agencies and issues concerned matters such as mental capacity, fitness to detain, transfer from custody to hospital, training regarding access to records and extradition.
DL – death in police custody following armed response unit bringing the deceased into custody. The deceased was in a camera cell on constant observations and attended by two nurses. The inquest over many weeks concerned issues including fitness to detain, mentally disordered detainees, alcohol withdrawal, capacity in custody and escalation of care.
NR – death in police custody following cardiac arrest related to methadone intoxication and alcohol withdrawal. The inquest over many weeks concerned issues including observation levels and rousing, communication between clinical and police staff, risk assessments and interagency handovers.
AM – death of a homeless alcoholic man known to the police and involving multiple contacts with the police immediately prior to the death. The inquest involved a range of issues including conveyance of members of the public to hospital in police cars.
Paediatric Deaths
EB – death of a child due to serogroup B Meningococcal septic shock. The child had attended A&E in the early stages of the disease but it was determined that there was nothing evident in her symptoms that would have indicated meningococcal disease.
AA – Inquest concerning the death of a child in a GP surgery following attendance at A&E. The child died of a rare congenital problem. The inquest concerned issues of assessment and admission criteria to a paediatric hospital.
SP – Article 2 inquest following the suicide of a 17-year-old boy jumping from a multi-storey carpark. The deceased had a complex history and was a Looked After Child. The inquest concerned his involvement with mental health services, the local authority and carers.
LL – death of a neonate in a maternity ward who did not undergo meconium observations she should have done.
JC – death of a child and concerning the diagnose and timely treatment of pertussis. A vast range of clinicians involved over two admissions into hospital. The inquest concerned the care provided by junior doctors in A&E, escalation, admission to intensive care and ECMO.
HF – death of a 2-month-old baby with significant co-morbidities including Edwards 18 Syndrome and complex cardiac abnormalities. She had multiple attendances at A&E culminating in a period of palliative care where she was administered an overdose of Oramorph. The body had been discharged to the family instead of the coroner.
LW – death of girl who died partly as a result of ventricular hydrocephalus which went undetected. Inquest concerned the signs, development and reasons for why the basis for this congenital issue was not detected.
HH – death following administration of anaesthesia. Issues in the inquest concerned the administration of anaesthesia and risk factors involved with this.
EL – death following treatment for vein of galen malformation. The procedure was highly specialised and provided in a dedicated centre. It involved complex medical evidence concerning neuroradiology and neonatal medicine.
FW – death concerning a neonate who was floppy at birth and underwent genetic testing which confirmed a diagnosis of Myasthenia Gravis which required immediate treatment. Central to the inquest was a conflict in evidence regarding two senior consultants about what was and was not communicated regarding the test results. The deceased was not admitted for treatment and died.
Medical Related Deaths
RM – death concerning fall at home and whether the deceased should have been conveyed by an ambulance to a minor injuries unit or A&E. The focus of the evidence was on the protocols and decision making of the ambulance service.
AB – death following failure to identify a false femoral artery aneurism. The deceased had multiple comorbidities but continued to complain of pain which was not picked up on. The case involved complex pre-inquest considerations.
SE – death following ERCP and biliary sphincterotomy to prevent recurrence of severe abdominal pain by reducing the pressure in the biliary sphincter. The deceased went on to develop severe post-ERCP pancreatitis. The inquest focussed on the procedure and technique employed for ERCP.
RD – death following chemotherapy treatment. The inquest involved, amongst other matters, the taking, recording and registering of blood results and the interaction between normal and out-of-hours primary care providers.
JN – death concerning a x 10 dose of Oramorph. Complex issues of causation arising as the deceased was on a palliative care pathway. The nurse administering the Oramporph had pending disciplinary proceedings and did not provide evidence in accordance with Rule 22 of The Coroners (Inquest) Rules 2013.
DT – death by suicide of a man following multiple contacts with his GP before death. The case concerned, amongst other issues, appropriateness of referrals from primary care.
FB – death of 71-year-old lady who had two admissions to hospital with abdominal pain. She was initially diagnosed with a urinary tract infection but the inquest considered whether more serious underlying pathology should have been considered.
BO – death of lady visited at home and then died of heart failure having been admitted to hospital. It was alleged that the family told their GP the deceased had fallen and this was not acted upon. The GP denied being told this information.
ML – death following overdose of heroin when the deceased had been an involuntary patient at a psychiatry facility. The inquest concerned, amongst other matters, the evaluation of risk by psychiatrists and nurses, mental health act assessments and detox programmes.
reflections
It may sound obvious but inquests are not easy for any interested person. I have seen countless families devastated by the loss of a loved one and incredulous that they are even caught up in the coronial process. They often seek lawyers who not only empathise with their plight but make the legal process accessible for them.
“At its core an inquest is not only an opportunity to address the death at hand but to understand how such deaths may be avoided in the future.”
For professional and institutional clients, their conduct is often under scrutiny and this can be very stressful. This is not least because of potential regulatory proceedings or negative reporting that may flow from any adverse findings. I’m always alive to these sensitivities. At its core an inquest is not only an opportunity to address the death at hand but to understand how such deaths may be avoided in the future. It is an opportunity for learning, but often with a lot at stake.