On 14 October 2024 the public inquiry into the death of Dawn Sturgess commences with hearings in Salisbury. Dawn Sturgess died on 8 July 2018 after being poisoned with Novichok, the nerve agent that had been used to poison Sergei and Yulia Skripal in Salisbury on 4 March 2018. As well as ascertaining how Dawn Sturgess came about her death, the Inquiry will consider the issue of Russian state responsibility.

The public inquiry, chaired by retired Justice of the Supreme Court Lord Hughes, will be holding hearings in Salisbury and London until 6 December 2024.

The inquiry has attracted significant media attention.

John Beggs KC and James Berry act for Wiltshire Police.

Bridget Dolan KC acts for South West Ambulance Service NHS Foundation Trust.

Cecily White presented the case against former PC John Apter, who was head of the Police Federation for England & Wales between 2018 and 2022 and at the time of the alleged misconduct.   Mr Apter was found to have made a sexually inappropriate comment about Lissie Harper, whose husband was a police officer killed in the line of duty, during preparations for an awards ceremony in January 2020.  Mr Apter has since retired from policing.

The Police Misconduct Panel concluded that Mr Apter would have been dismissed had he still been a serving police officer with the consequence that his name will be added to the Barred List maintained by the College of Policing.  Other allegations were found not proven.

The case received significant press coverage from the BBC, The Guardian and the Times Series.

Congratulations to James Berry who was awarded Public Services and Charities Junior of the Year, and Rhys Hadden, who was award Court of Protection Junior of the Year at the Legal 500 UK Bar Awards 2024.

Thank you to all our clients and contacts for their continued support throughout the research process.

Recent Legal 500 testimonials for James and Rhys include:

• ‘James is one of the best juniors. Very clever, great strategic brain, and a calm and authoritative style in court.’
• ‘James is incredibly approachable, good with clients of all ranks and matches this with an excellent grasp of police law. His advocacy is understated – which suits the subject matter – but highly effective.’
• ‘Rhys is a very experienced and specialist barrister. His engaging and collaborative approach ensures cases progress quickly and efficiently. His advocacy style is thorough, engaging and effective.’
• ‘Rhys brings a wealth of knowledge to proceedings when dealing with difficult exclusion matters and school governors. Clients value his ability to cut through the extraneous matters and focus on what is important.’

This week the Investigatory Powers Tribunal (Singh LJ, Lady Carmichael and Stephen Shaw KC) is considering a significant claim brought by two Northern Irish journalists, Barry McCaffrey and Trevor Birney.

The Tribunal will consider the Claimants’ complaints including that their journalistic material was obtained unlawfully in criminal investigations into the alleged leaking of confidential information by public servants.

The investigations were undertaken by and on behalf of the Police Service of Northern Ireland.

The case has attracted national media coverage.

James Berry and Chloe Hill act for the Metropolitan Police Service.

They are also acting in a similar claim brought by the BBC and BBC journalist Vincent Kearney which will be heard by the Tribunal in due course.

In London Borough of Islington v A Parent [2024] UKUT 252 (AAC) Upper Tribunal Judge Stout (building on the decision in AJ v London Borough of Croydon [2020] UKUT 246 (AAC)) has clarified: (1) the obligations imposed on the First-tier Tribunal (HESC) (“FTT”) when exercising its inquisitorial jurisdiction to determine appeals concerning Education Health and Care Plans and (2) the way in which the ‘burden of proof’ principle operates in this jurisdiction.

Judge Stout held that:

• The FTT erred in law by placing a formal burden of proof on the Local Authority. The FTT’s task on appeal is to “stand in the local authority’s shoes” and apply section 39(4) of the Children and Families Act 2014 properly to the facts of the case before it, exercising its inquisitorial jurisdiction to ensure it has the necessary evidence on which to fairly determine the appeal: [54]-[60].
• The FTT did not, at the hearing, explain that it was unable to make findings as to the cost of either placement nor did it canvas with the parties what should be done about that: [53]. Fairness required the FTT to put its concerns to the Local Authority at the hearing (or, if it thought of the concerns only in the course of deliberation, to give the Local Authority a further opportunity in writing or at an adjourned hearing to address those concerns): [63].
• The school of parental preference in this case fell in another geographical area. The FTT failed to properly consider its case management powers to (1) require the parties and/or the third party Local Authority and school to provide further evidence and/or (2) order a witness from the third party Local Authority or school to attend the hearing: [63]. Such powers were available to the FTT, but not the Local Authority responsible for maintaining the EHC Plan: [61].
• On the facts of this case, it was perverse for the FTT not to adjourn the hearing for further evidence, since the prejudice to the parent and child would have been minimal compared to the potential prejudice to the Local Authority to fund the child’s placement at a school at very significant additional cost to the public purse: [70].
• The FTT’s task is to find out what the difference (or approximate difference) is between the costs of the two placements on the balance of probabilities. The fact that the FTT considers those costs to be unreasonable or inadequately explained will not normally be a basis for finding that those are not the actual costs. That is especially so where the school in question is not one the Local Authority is responsible for funding: [81].
• The FTT failed to make any determination about the suitability of the school preferred by the Local Authority. On the parent’s case, those were all matters that were in dispute. The Upper Tribunal gave guidance reminding the FTT that it should normally make findings on the evidence it hears so that, in the event of an appeal, cost and public resources do not need to be wasted in an unnecessary rehearing. Dealing with a question of costs alone is the sort of issue that could normally be remade at Upper Tribunal level. The FTT’s decision not to complete its fact-finding function in this case, however, meant that the appeal needed to be remitted: [87]-[88].

The judgment can be found here.

Benjamin Harrison, of Serjeants’ Inn Chambers, was instructed by Hannah Connors on behalf of the successful appellant.

Parsing judgment: judicially reviewing decisions of the Police Appeals Tribunal

In an admirably in-depth judgment, the Court in R (Stephen Dalton) has considered on what bases decisions of the Police Appeals Tribunal (‘PAT’) may be properly subject to judicial review. The decision reiterates the ambit of the PAT’s discretion and is likely to affect how such proceedings are conducted going forward.

The misconduct proceedings

The relevant misconduct occurred when the claimant police officer, along with his colleagues, responded to a report that three youths were attempting to break into a bike shed. The claimant arrested and handcuffed one of the individuals, Richard Smith, walked him to the rear of a nearby police car, and forced his head downwards onto the vehicle. This caused Mr Smith to suffer lacerations to the face and possibly a fractured jaw.

Mr Smith complained that the claimant’s actions breached the Standards of Professional Conduct as set out in the Police (Conduct) Regulations 2012 (in effect at the time). A Police Misconduct Panel (‘the Panel’) considered an array of evidence and concluded that the claimant was solely responsible for the use of excessive force and the lack of respect and courtesy shown to Mr Smith, and that his conduct was intentional and deliberate. The Panel dismissed the claimant without notice.

The claimant appealed to the PAT. The Chair of the PAT (‘the Chair’) conducted a review of the appeal under Rule 11 of the PAT Rules 2012 and dismissed it on the basis that it had no realistic prospect of success. The claimant applied for permission to judicially review the PAT’s decision.

The Court’s decision

Mrs Justice Lang, refusing the claimant’s application for judicial review, closely analysed the reasoning of both the Panel and the PAT. The main grounds of review and the reasoning of the Court are summarised below.

(i) Irrationality

The claimant alleged that the Chair acted irrationally in concluding that the evidence of two of the claimant’s colleagues, both of whom were on the scene when Mr Smith was arrested, was “not hugely significant.” Mrs Justice Lang held that this ground was “unarguable” and had no realistic prospect of success. The Panel had based their conclusions on high-quality Body Worn Video which contradicted or undermined key parts of the claimant’s evidence, rendering it unreliable. It was entirely rational for the Chair to reach the decision he did. In the alternative, Mrs Justice Lang considered that permission should be refused under section 31 Senior Courts Act 1981.

(ii) Failure to properly analyse the issue of apparent bias

The claimant submitted that the PAT had failed to properly engage with his contention that one of the Panel Members had acted in a manner that gave rise to an appearance of apparent bias. Mrs Justice Lang concluded that this ground was also unarguable and had no realistic prospect of success. The Panel was entitled to ask searching questions, and none of the language used was unfair or biased. The Panel Member was neither a trained lawyer or judge and was therefore entitled to some latitude in the phrasing of her questions. The Chair had applied the correct legal test and assessed the questions in their proper context.

(iii) Failure to give adequate reasons

The claimant alleged that the Panel had erred by (i) making findings in respect of witness credibility before resolving certain inconsistencies in the evidence presented to them, and (ii) failing to properly refer to the good character evidence presented to them. In turn, the PAT had failed to give adequate reasons for rejecting that ground of appeal.

Mrs Justice Lang rejected both of the claimant’s submissions. On the first issue, she concluded that it sought to “re-open the evidential issues under the guise of a failure by the PAT Chair to give adequate reasons.” After reiterating that judicial review is not an appeal on the merits, she held that the claimant’s argument turned entirely on how the Panel had drafted its judgment. This was a matter squarely within its discretion. In any event, it was clear that the Panel had considered all the evidence, decided which it accepted and which it rejected, and made its findings of fact. On the second issue, she concluded that the Panel was not required to refer to the character direction in their decision – they were merely required to take it into account. In the alternative, were she wrong on either ground, Mrs Justice Lang considered that permission should be refused under section 31 Senior Courts Act 1981.

Commentary

Mrs Justice Lang’s judgment reiterates a number of important principles of law that must be borne in mind by both tribunals and reviewing courts alike. First, although it is crucial to maintain the highest standards of procedural fairness, misconduct panels have some discretion over how misconduct proceedings are conducted, and their independent members are not to be treated in the same manner as professional lawyers or judges. Appeals brought on the basis that the tribunal did not operate as a court might be expected to in criminal proceedings are unlikely to be successful (see Simon Brown LJ’s comments on the purpose of misconduct proceedings in Redgrave). Second, reviewing courts should be careful not to venture into unsuitable terrain and make a decision on the merits of the case, however the claimant’s application may be formulated. Perhaps such reminders will serve to reduce the number of ‘unarguable’ cases that come before the courts in future.

Matthew Holdcroft represented the Chief Constable of Hertfordshire Constabulary as the Interested Party, who acted as the Appropriate Authority at the misconduct proceedings. The Court upheld his submissions on all grounds.

Rachel Spearing has been appointed as a Patron of The Next 100 years after many years of being a member. Rachel joined The First 100 Hundred Years Pioneers for the 1990’s, celebrating her diverse background and co-founding of the Wellbeing at the Bar initiative in 2012.

The Next 100 Years is a project dedicated to achieving equality for women in law. They are focused on encouraging collaboration across the profession, improving the visibility of women in law, and supporting the women lawyers of the future.

The ten-year project is powered by Spark21, a charity founded to celebrate, inform and inspire future generations of women in the profession. It builds on the success of the First 100 Years project, created to chart the journey of women in law in the first 100 years following the Sex Disqualification (Removal) Act 1919, which allowed women to become lawyers for the first time. The five-year project culminated in centenary celebrations in 2019.

The Next 100 Years will continue the work of the First 100 Years, capturing the inspirational stories of today’s pioneering women lawyers, educating the public on the legacy of the legal pioneers of the past, and driving the change needed to create an equal future for women in the profession.

Speaking about the project Rachel says: “As a Patron of the Next 100 Years ‘paving the way’ for this next generation for me means supporting their access to, resilience within, and successful retention or return to the profession. Building greater awareness of their challenges is what I aspire to do as a Leader.”

Visit their website here.

A concise practice review was commissioned by Mid & West Wales Safeguarding Children Board following the tragic death of Lola James, a young child, as a result of an unprovoked and violent attack by her mother’s partner.

Emma Sutton KC was appointed as the independent reviewer and was responsible for drafting the report published today.

A copy of the full report together with a 7 minute briefing is available here, the 11 recommendations are as follows:

” 1. For the corporate management team within the local authority to ensure that guidance for heads of service regarding additional funding requests is readily available and understood, and to consider how internal funding decisions can be reviewed if a request for additional funding is rejected. This is particularly important within social services due to the statutory
nature of this service, and the need to maintain an effective operating level in line with statutory duties. Where these pressures are not able to be met or statutory duties are compromised, this should be highlighted clearly in the director of social services’ annual report for the attention of elected members and the public.

2. For training to be arranged for practitioners and managers within children’s services regarding the assessment/sign off process, and for senior officials within children’s
services to ensure there is a robust process in place for auditing assessments. For senior officials to also review whether the current supervision arrangements for both social workers and team managers is appropriate, and to urgently review whether other assessments within children’s services have been completed and closed in a similar way to child A, and to consider whether this review should be undertaken independently. Practitioners within adult services to be reminded in supervision meetings of the need for wider consultation with relevant professionals when undertaking adult needs assessments.

3. For senior officials within children’s services, in conjunction with HR, to ensure that a policy is in place regarding how staff are supported when sickness issues arise to avoid crisis/ prolonged staff leave, and to address how cases are managed when staff are on sick leave. The latter point to include consideration of how records are managed when staff are on sick leave, and for such issues to be considered as part of the return to work and sickness absence review processes.

4. For senior officials within children’s services to finalise a template for rapid reviews to be undertaken effectively and timely following a child’s death or serious incident in an open or recently closed case. Consideration should also be given to how that rapid review process can (itself) be reviewed to ensure its effectiveness.

5. Agencies to review and provide assurance that training and guidance is available to multiagency practitioners in respect of completing and understanding thresholds for completing Multi-Agency Referral Forms (“MARFs”), and for a robust quality assurance process to be put in place to ensure that the MARF process is correctly and effectively utilised by practitioners.

6. Agencies to consider mechanisms which would facilitate multi-agency decision making and collaborative practice in respect of children and families where concerns fall below the threshold of significant harm, including the formation of multi-agency safeguarding hubs, and for consideration for such hubs to meet “virtually” having regard to the wide geographical area.

7. Agencies to ensure that sharing policies and practice guides are up to date in line with current legislation, policy and procedures, for further training to be undertaken on information sharing, and for an audit on staff training to be undertaken. This relates to CYSUR 1 2021 Child Practice Review Report CYSUR 1/2021 Report Page 30 of 35 information sharing between practitioners and information between professionals and a non-resident parent.

8. Information sharing between compulsory education and early years settings to be explored by local education services to facilitate sharing of sibling information, alongside national consideration of this issue (see CIW report commissioned by the Welsh Government, September 2023).

9. Multi-agency training to be undertaken and greater managerial support for complex cases where there are difficulties engaging with parents or carers, and for a robust quality
assurance process to be put in place to evidence that training/greater managerial support (regarding the issue of difficulties with parental engagement/engagement with other relevant persons, etc) is being addressed.

10. Regional police force to pursue implementation of a flagging mechanism of a specific address (within the operational database) where there is a wider history of safeguarding concerns linked to that address (absent an incident being logged as a “domestic” incident).

11. For supervision sessions with relevant practitioners within the respective agencies to address the importance of using specific terminology when completing records/reports, and for professionals to be reminded of the importance of providing sufficiently detailed/ contemporaneous records. This is to include making it clear which individual(s) in or around a family are being referred to. “

Coverage from Sky News is here.

Serjeants’ Inn are delighted to announce the following 21 nominations at The Legal 500 UK Bar Awards 2024:

• Set of the year
• Clinical Negligence Set of the year
• Court of Protection Set of the year
• Professional Disciplinary Set of the year
• Public Law Set of the year
• Public Services and Charities Set of the year
• John Beggs KC for Public services and Charities Silk of the year
• Michael Mylonas KC  for Clinical Negligence Silk of the year
• Nageena Khalique KC for Public Law Silk of the year
• Bridget Dolan KC for Court of Protection Silk of the year
• Sarah Clarke KC for Financial Services and Insurance Silk of the year
• Mark Harries KC for Professional Disciplinary Silk of the year
• Scott Matthewson for Personal Injury Junior of the year
• Ranald Davidson for Professional Disciplinary Junior of the year
• Heidi Knight for Clinical Negligence Junior of the year
• James Berry for Public services and Charities Junior of the year
• Rhys Hadden for Court of Protection Junior of the year
• Aaron Rathmell for Public services and Charities Junior of the year
• Cecily White for Public Law Junior of the year
• Marketing Team of the year

Thank you to all our clients for taking the time to participate in the research and good luck to all the different chambers and counsel nominated!

Please see the full The Legal 500 UK Bar Awards 2024 shortlist here.

Hannah Hinton, led by Mark Summers KC, instructed by Coomber Rich Solicitors, argued prison assurances given by Romania were inadequate.  They successfully argued that a District Judge incorrectly refused to receive evidence on the issue on a remitted Part 1 appeal.  The case provides clarification on the approach of District Judges in remitted appeals. See the judgment here.

The Inquiry found that the UK government and the devolved nations had failed its citizens in its emergency planning. The structures and institutions were too complex.

There were significant flaws underpinning the assessment of risks, how they and their consequences could be managed and how they could be responded to.

The UK, in preparing only for an influenza pandemic, prepared for the wrong pandemic. 10 recommendations are made for radical reform to the way in which the civil contingency structures prepare for whole system civil emergencies.

10 recommendations are made for radical reform to the way in which the civil contingency structures prepare for whole system civil emergencies.  A copy of the report by The Rt Hon the Baroness Hallett DBE Chair of the UK Covid-19 Inquiry is here.

Bridget Dolan KC and Rachel Spearing acted for the Health Security Agency, Debra Powell KC and Susanna Rickard acted for Public Health Wales, Ed Pleeth and Frances McClenaghan acted for the Cabinet Office and Sarah Simcock acted for the Department of Energy.

The Inquiry continues with a further 8 modules due to address various aspects of the pandemic including the central government response, PPE procurement and the government’s economic response. Hearings are expected to conclude in 2026.

In a highly publicised case before the Medical Practitioners Tribunal it was alleged that Mr A, a well-known spinal surgeon, performed a number of complex spinal operations that were not appropriate or clinically indicated. It was further alleged that Mr A acted dishonestly in relation to claims for remuneration for various procedures and in discussion about an alleged surgical complication.

The case, which had been listed to last for around six weeks, was brought to a close within just a fortnight when the tribunal acceded to the Defence’s ‘half time submission’, made following cross-examination of the GMC’s expert, that there was ‘no case to answer’. The tribunal made no adverse findings against Mr A. It held that there was no misconduct and that Mr A’s fitness to practise was not impaired.

Mr A was represented by Andrew Hockton, who was instructed by Charlotte Ellis of DWF Law LLP.

Andrew Hockton’s profile is here. He is a winner of the Chambers and Partners Professional Discipline Junior of the Year Award.

Seven Barristers of Serjeants’ Inn Chambers have been named on the inaugural Pro Bono Recognition List 2024. The list is a new initiative that recognises barristers and solicitors who have given 25 or more hours of pro bono legal assistance over the previous calendar year.

Congratulations to Katie Gollop KC, Mark Harries KC, Rachel Spearing, Rhys Hadden, Aaron Rathmell, Jake Rylatt and Rachel Gourley.

If you have already completed 25 or more hours of pro bono work in 2024, make sure to complete the submission form to appear on next year’s Recognition List.

Read more about the publication of the Pro Bono Recognition List here.

Angus Moon KC has been instructed as leading counsel on behalf of the appellant in the appeal to the Supreme Court in the case of Lewis-Ranwell v G4S Health Services (UK) Ltd.

The case addresses the question of whether a killer who was found not guilty by reason of insanity may obtain damages in relation to 3 killings from the health body which treated him. Angus’ instruction follows his successful appearance in the Supreme Court in Henderson v Dorset Healthcare University NHS Foundation Trust in 2020. Permission to appeal in Lewis-Ranwell was granted by the Supreme Court on 28th May 2024.

Read more on the case below here.

A bereaved family represented by Bridget Dolan KC have called for an independent review into mental health services following the tragic death of Dr Kim Harrison (Kim) in 2022. Kim was assaulted by his son, Dan, who had been formally detained under the Mental Health Act; but less than an hour before the assault he had absconded from the ward in Neath Port Talbot Hospital whilst a staff member was conducting a conversation at an open door. Dan had been detained as he was considered to be a risk to others. At the time of the assault Dan was suffering from untreated schizophrenia which caused him to have paranoid delusions about his father.

The inquest revealed numerous failures by Swansea Bay University Health Board (SBUHB) in the care of Dan which had contributed to Kim’s death. The coroner found that before the killing, over a number of months, the Harrisons had raised their concerns with SBUHB staff on multiple occasions regarding the perceived failures in SBUHB’s management of Dan’s mental health; including writing to the SBUHB Interim Chief Executive, the Medical Director, the Nurse Director for the Mental Health & Learning Disabilities Service Group and other members of SBUHB’s senior management team.

The Coroner has now issued a ‘prevention of future deaths’ report (here) highlighting the shortcomings of the Health Board and the City and County of Swansea Local Authority including:

• The failure to put in place appropriate and timely follow up arrangements when Dan’s consultant left the service.
• The failure to ensure that Dan was regularly and assertively visited in the community so that he could be re-engaged with mental health services.
• A flawed Mental Health Act (MHA) assessment of Dan in early 2021.
• Failure of an AMHP  to comply with their s.13(4) MHA duty and to collect sufficient collateral information before visiting and assessing Dan under MHA.
• The defective security system and lack of adequate training of staff regarding door access on the ward, which was being operated in an unsafe manner.
• Failure to properly address Kim and Jane Harrison’s complaints about Dan’s care which they raised before the killing – when an independent report was commissioned by the Health Board but then was, inexplicably, not shared with the consultant psychiatrist whom it criticised at any point prior to Kim’s death.

Following an investigation by the Sunday Times which highlighted the scale of mental-health related killings in Britain, Dr Jane Harrison, Kim’s wife, said that she believes “the NHS has become used to poor mental health care and is tolerating the deaths that happen as a result.” Earlier she had told the BBC that she believed her son was let down at all stages of his mental health care, and that her “family has suffered immeasurable harm at the hands of managers and senior clinicians.”  Dan is as much a victim of this tragedy as his father.

Bridget Dolan KC is instructed by Joanna Bennett of Bindmans. You can read more about this case, as well as Bridget’s involvement, here.

Read the PFD report here.

We are delighted to announce that Nageena Khalique KC has been appointed as leading counsel to represent the Welsh Government in Module 6 of the Covid-19 Inquiry. This module commenced in December 2023, with public hearings expected to take place in the summer of 2025.

Module 6 will investigate the impact of the Covid-19 pandemic on both the public and private adult social care sector in England, Scotland, Wales, and Northern Ireland. It will grapple with difficult issues concerning the consequences of government decision-making on those living and working in the care sector, including, but not limited to, hospital discharge to care homes after the introduction of government restrictions, restrictions on visitors to care homes, and the availability of PPE for the care sector. You can find out more information about the scope of Module 6 on the Covid-19 Inquiry website.

The decision was taken by senior officials of the Welsh Government after a competitive interview process. It was based on Nageena’s specific experience and expertise of the care sector, including its structure and the complex policy and legal issues that arise in the area. Please click here for more information about Nageena’s practice in health and welfare law.

Scott Matthewson has just returned from Argentina where the adversarial system of trial is being newly implemented. Scott was part of a four-person team advising leading Argentine judges, lawyers and academics on the adversarial system in England & Wales and training lawyers in the method of advocacy training adopted by the Inns of Court. Scott joined Joanna Korner CMG KC (British Judge of the International Criminal Court in the Hague), Professor Cheryl Thomas KC (UCL) and Upper Tribunal Judge Jill Frances. Supported by the British Embassy and funded by UCL, ROLE UK and the Inner Temple, the team delivered a series of seminars, lectures and workshops to lawyers, judges and government ministers in Buenos Aires and to the Supreme Court in Salta. The team plans to return in the coming years to advise on the roll out of a new Argentinian advocacy programme across the country.

Read more about it on the Argentinian State Website here.

Read more about Scott’s practice here.

On Monday 13th May a panel discussion was held in Oxford to give students the opportunity to find out about careers in Medical Law and Ethics.

The panel consisted of representatives from the Bar (John de Bono KC and Katherine Hampshire of Serjeants’ Inn Chambers), from two firms specialising in medico-legal matters (Rob Tobin, Head of the Medical Law team at Kennedys, and Flora Jago, a senior solicitor at Hempsons), and from academia and policy (Jonathan Herring, Professor of Law at University of Oxford and Imogen Goold, Professor of Medical Law, University of Oxford and pupil at Serjeants’ Inn).

We are delighted to be nominated for 3 categories at The Legal Cheek Awards this year. These include:

• Best Chambers for Quality of Work 2024
• Best Chambers for Colleague Supportiveness 2024
• Best Chambers for Legal Tech 2024

Congratulations to everyone else who has been nominated and thank you to all our clients for your support.

Read the full list of nominees here.

Anthony Searle, instructed by Sanja Strkljevic and Ella Cornish of Leigh Day, represented the bereaved daughter of Tracey Farndon at the resumed inquest into her death on 4 April 2024.

Tracey, an otherwise healthy 56-year-old woman, attended the Emergency Department at Queen Elizabeth Hospital in the early hours of 25 April 2023. She died the same day from septic shock, caused by sepsis secondary to community-acquired pneumonia. Not a single healthcare professional suspected sepsis at any point prior to Tracey’s death, despite signs being present.

Mrs Louise Hunt, HM Senior Coroner for Birmingham and Solihull, heard evidence from Tracey’s daughter and partner, as well as a Consultant in Emergency Medicine, a Consultant Thoracic Surgeon and an Emergency Department Matron.

Anthony’s questioning and legal submissions led the Senior Coroner to accept that there was sufficient evidence to justify the serious finding of neglect. The Senior Coroner considered that there was a gross failure to provide basic medical attention in the form of obtaining Tracey’s blood pressure reading and NEWS2 score shortly after her arrival. Had these gross failures not occurred, a different pathway would have been triggered, including a medical assessment of Tracey, various investigations, and the commencement of the Sepsis Six pathway. The Senior Coroner considered these gross failures to be causative of Tracey’s death.

As a result of the deficiencies in her care, Tracey was left without a full set of observations (and any repeat observations) for around 5 hours following her arrival, she had no medical assessment for over 6 hours, and she was never given antibiotics. The staffing levels and overcrowding in the Emergency Department were significant contributory factors hindering healthcare professionals’ ability to give Tracey the care she needed.

As well as making the rare finding of neglect, the Senior Coroner considered it appropriate to write two Prevention of Future Death (‘PFD’) Reports. The first will be sent to the Department of Health and Social Care because the Senior Coroner has serious ongoing concerns about resourcing in emergency departments. The second will be sent to University Hospitals Birmingham NHS Foundation Trust owing to a continued significant lack of understanding of sepsis.

The result of the inquest has been the subject of media attention (BBC, The Mirror, Birmingham Mail). The PFD reports are awaited and will be published here.

Anthony is a specialist in clinical negligence and healthcare-related inquests. He has significant experience in cases involving sepsis. His profile can be viewed here.

Sabina Rizvi was murdered in the early hours of 20 March 2003. Around a week earlier her boyfriend MW had, it was alleged, robbed PA of his Audi TT. In the subsequent days PA sought the assistance of Metropolitan Police Service in recovering the car while Sabina and MW sought to assert genuine ownership of it. On 19 March 2003 Sabina attended Bexleyheath Police Station to give a voluntary statement about her alleged purchase of the car. At the police’s request the car was brought into the Station by her boyfriend who arrived wearing a bullet proof vest. He was arrested and interviewed. Following his interview MW provided information about a threat to his life made by PA. He was released on bail. Within minutes of Sabina and MW leaving the station they were ambushed and shot multiple times. MW was very seriously injured. Sabina tragically died. PA was convicted of Sabina’s murder but his two accomplices have never been identified to the criminal standard of proof.

The inquest into Sabina’s death was resumed after a campaign by her family. It was held in Court No.1 of the Old Bailey before HHJ Rafferty KC sitting as Assistant Coroner, over 14 days. The inquest focussed on (1) whether the police deliberately notified PA and/or others of the whereabouts of MW; (2) whether the police inadvertently notified PA and/or others of the whereabouts of MW; and (3) whether the police knew or ought to have known that an attack would or might take place and whether steps could or should have been taken to prevent it.

After hearing extensive submissions, the Coroner concluded that there was insufficient evidence to leave any of these issues to the jury and directed the jury to return a conclusion on Unlawful Killing.

For press coverage see: https://www.bbc.co.uk/news/articles/ckd87z4nr5yo

https://www.bbc.co.uk/news/uk-england-london-68632098

John, James and Cecily appeared for the Metropolitan Police Commissioner. They frequently appear in high profile inquests and inquires and related litigation.

We are delighted to announce that Nageena Khalique KC has been awarded Advocate of the Year at The Women & Diversity in Law Awards 2024.

As the first female Asian deputy High Court judge in the Family Division and co-founder of Facefacts charity, Nageena has made significant contributions to diversity, equity, and inclusion within the legal profession.

Nageena’s work often champions the rights of vulnerable members of society, particularly in serious medical treatment cases that impact reproductive rights, sexual autonomy and religious beliefs.

In addition, she has provided mentoring and motivational speaking to aspiring female barristers and a Birmingham school with large cohorts of Muslim and Asian children.

For more details on Nageena’s practice, please click here.

Conrad successfully represented Luton Borough Council in the Court of Appeal in the Official Solicitor’s appeal of the decision of a High Court Judge that it was in the best interests of P, a young man with significant learning difficulties, not to travel to Afghanistan with his extended family, who had previously gained asylum in the UK but were planning a trip to their country of origin. In the first case of its kind, the Court of Appeal refused the Official Solicitor’s appeal on the basis that the first-instance judge had erred by giving too much weight to the Foreign Office Guidance not to travel.

Jamie Mathieson had previously successfully represented Luton Borough Council in the High Court.

Read more about Conrad’s practice here.

Read more about Jamie’s practice here.

Sophia Roper KC and Benjamin Harrison acted for the Official Solicitor in Aberdeenshire Council v SF, EF and Sunderland City Council [2024] EWCOP 10 where they successfully persuaded Poole J to refuse to recognise a Scottish Guardianship Order. The Guardianship Order purported to grant P’s mother the power to authorise the deprivation of P’s liberty for a seven year period without any means of effective review.

The court found that the Scottish Guardianship Order was made in a manner which (i) did not give P an opportunity to be heard in circumstances which (ii) breached of the principles of natural justice, and (iii) breached P’s fundamental human rights under Articles 5, 6 and 8 ECHR.

This case is the only reported example of the Court of Protection exercising its discretion to refuse to recognise a foreign protective measure which was made in another jurisdiction within the UK. Sophia and Ben were instructed by Caroline Hurst of Simpson Millar LLP.

Read more about Sophia’s practice here.

Read more about Ben’s practice here.

Serjeants’ Inn is one of 21 chambers to be awarded the new Certificate of Recognition issued for an “innovative and invaluable contribution made to the well-being initiative in the profession”.  Noting our “breadth of thought, support and safeguarding”,  the Bar Council comments: “Serjeants’ Inn clearly demonstrate a deep understanding of this agenda and have been strategic in recognising the need to tackle stress points as well as introduce new initiatives”.  Further details available soon on the excellent  Bar Council Well-Being site here. Thanks to the Bar Council for its continuing drive to promote well-being within the profession, and congratulations to all the other organisations achieving  this recognition.