Davison v HM Senior Coroner for Hertfordshire [2022] EWHC 2343 (Admin) (15 September 2022)

Megan Leanne Davison (“Megan”) had the misfortune to suffer from Type 1 diabetes and diabulimia, a psychiatric disorder which involves the deliberate omission of insulin doses. Very sadly, she took her own life on 4 August 2017, aged just 27. At an inquest held on 28 March 2018, HM Senior Coroner for Hertfordshire (“the Coroner”) concluded that Megan’s death was suicide. He did not make a prevention of future deaths report (“PFD report”). By a claim issued on 11 October 2021, with the fiat of HM Attorney General, Megan’s mother (“Mrs Davison”) applied for an order under section 13 of the Coroners Act 1988 quashing the Coroner’s conclusion and directing a fresh investigation be held. At the conclusion of the hearing we announced that the application would be granted and a fresh inquest directed… [1]

In July 2020 Mrs Davison sought the fiat of HM Attorney General to enable her to make this application to the High Court. HM Attorney General obtained a report from Professor Khalida Ismail… [11]

Prof. Ismail made a number of criticisms of the care which Megan had received, and expressed her opinion as to the potential value of a new inquest in increasing understanding of the nature and incidence of diabulimia, which could lead to more screening and assessment of patients and so reduce the number of deaths. [13]

Having considered Prof. Ismail’s report, the Attorney General authorised the making of this application. [14]

Prof. Ismail’s report… indicates that there is a need for better coordination between different disciplines in the treatment of those suffering from both Type 1 diabetes and diabulimia; that there may be deficiencies in the general care of such persons; that warning signs and “red flags” were not acted upon in Megan’s case; and that inadequate care may have contributed to Megan’s decision to take her own life. Those features of the report have obvious implications for any consideration of the nature and standard of the care which Megan received, and of whether a PFD report is appropriate. Thus the new evidence not only adds important information but also casts a different light on the other evidence which was appropriate to be considered by the Coroner, and on the assessment of that evidence. [29]

…the discovery of new evidence makes it necessary or desirable in the interests of justice that a fresh investigation should be held. [30]