Coroner applies for orders quashing an inquest held on 29 June 2017 into the death of Edward John Masters and directing a fresh investigation into his death. A similar application is made in respect of an inquest held on 12 December 2013 into the death of Mary Helen Rooker. Each of the deceased died whilst a patient of the vascular surgery unit at the Royal Cornwall Hospital (“the hospital”). The applications raise issues in common, and it is convenient to hear both together and to address the issues in this single judgment of the court. [1]
The applications are made pursuant to section 13 of the Coroners Act 1988 [2]
Each of the applications is made pursuant to section 13(1)(b) on the ground that new facts and evidence make it necessary and desirable for a fresh investigation into the death to be held. [3]
Mr Masters was aged 80 at the time of his death on 17 January 2017. On that day, he underwent elective surgery by the surgeon to repair an abdominal aortic aneurysm. [5]
The fresh evidence which is now available, but which was not available at the time of the original inquest, reveals shortcomings in the consent process which was carried out before the operation and in the care and treatment of Mr Masters during his operation. It raises the possibility that the death was contributed to by acts and/or omissions of the surgeon. [8]
Mrs Rooker was aged 71 at the time of her death. She too underwent elective surgery for the repair by the surgeon of an abdominal aortic aneurysm. [11]
The fresh evidence which is now available, but which was not available at the time of the original inquest, includes an expert report [which] points to negligence on the part of the surgeon in proceeding with the operation despite Mrs Rooker’s low platelet count, to a lack of informed consent by Mrs Rooker having regard to the risks involved in the procedure, and to an unacceptable standard of aspects of Mrs Rooker’s treatment by the surgeon. The evidence also raises the possibility that her death was contributed to by acts and/or omissions on the part of the surgeon and by a collective failure of care and systems at the hospital. [14]
we are satisfied that by reason of the discovery of new facts and evidence, it is both necessary and desirable in the interests of justice that another investigation should be held. In each case, we accordingly allow the claim. We quash the determination and findings of the original inquest, and we direct that a fresh investigation and inquest be held. [21]
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