Chidlow, R (On the Application Of) v HM Senior Coroner for Blackpool and Fylde [2019] EWHC 581 (Admin) (12 March 2019)

Carl Bibby fell ill in the night of 27/28 July 2009. An ambulance was called but there was admitted delay in the response of the North West Ambulance Service NHS Trust (NWAS). During that delay, Mr Bibby suffered cardiac arrest and died. He was only 38 [1]

At the inquest in respect of his death, the jury heard evidence from a consultant in Critical Care & Emergency Medicine that had paramedics attended Mr Bibby before he suffered cardiac arrest, he would, on the balance of probabilities, have survived. Nevertheless, the coroner ruled that it was not safe to leave the issue of a causal link between the delay and Mr Bibby’s death to the jury. By these judicial review proceedings, Mr Bibby’s brother, John Chidlow, seeks a declaration that the coroner acted unlawfully, an order quashing the record of inquest and an order that a fresh inquest be held before a different coroner. [2]
… the cause of death was unascertained… there was no evidence of any natural disease… [13]

At the conclusion of the evidence, the coroner received legal submissions as to, among other matters, the availability of a conclusion of neglect by reason of NWAS’s delay in attending upon Mr Bibby and whether he should direct the jury to consider a possible causal link between such delay and death. The coroner ruled that neither matter should be left to the jury. [28]

… the question of a causal link between the delay in the attendance of the ambulance service and death should have been left to the jury in this case if there was sufficient evidence upon which the jury could safely find that, on the balance of probabilities, such delay had more than minimally, negligibly or trivially contributed to Mr Bibby’s death. For completeness, a coroner also has a discretion, but not a duty, to leave to the jury causes of death that are merely possible but not probable: R (Lewis) v. Mid & North Shropshire Coroner [2009] EWCA Civ 1403, [2010] 1 WLR 1836, per Sedley LJ at [28]. [37]

The essence of the coroner’s ruling was… his view that any evidence as to survivability was necessarily speculative, and therefore unsafe, given the absence of clear evidence as to the cause of death. In my judgment, the coroner fell into error in concluding that the lack of a clear cause of death prevented the jury from being able to consider the possible causal effect of the delay in treatment. The pathologists and [the A&E consulant] were not addressing the same issue. Establishing the medical cause of death would plainly have assisted but was not… essential to being able to form an opinion as to the effect of delayed treatment… [63]

… the coroner erred in law and that the issue of the causative effect of NWAS’s admitted delay in attending to Mr Bibby should have been left to the jury… I would therefore quash the record of inquest and remit this case for a fresh inquest. [65]