C seeks an order for a fresh inquest into the death of his sister, Ms Zoe Morrow. C proceeds with the Attorney-General’s fiat dated 20 November 2023. [1]
Zoe was found dead on the floor of her bedroom on 12 April 2021. Medication was found in her pockets, an empty daily medication container was found on the bed, a number of empty blister packs were in the waste bin in the bedroom and a quantity of prescription medication was found in her living room. A post-mortem examination and toxicology analysis indicated the presence of multiple drugs in her blood at the time of death. Those drugs were at fatal levels and, taken together, they are known to have overlapping adverse effects. Zoe was 41 years old when she died. [2]
Prior to her death, Zoe had been under the care of Mersey Care NHS Foundation Trust, named as the Interested Party. Following her death, the Trust undertook a rapid review (the “72 hour review”). It then conducted a root cause analysis which was finalised on 15 March 2022 (the “comprehensive review”). The Trust identified a number of gaps, shortcomings and missed opportunities in the care provided to Zoe. But the Trust concluded that none of these identified gaps, shortcomings or missed opportunities caused or contributed to Zoe’s death. [3]
An inquest into Zoe’s death was held on 31 March 2022, presided over the “Coroner”. The Coroner concluded that the cause of death was “1A Mixed Drug Toxicity”. [4]
C are of the view that Zoe’s mental health was not properly managed by the Interested Party and that failures by the Interested Party contributed to her death. C asks this Court to order a fresh inquest to address the various points which he says were overlooked by the Coroner, to put right the various procedural failings at the first inquest and to offer him and his family the opportunity to argue for a conclusion of suicide. [11]
I hope C will not mind if I rearrange their case a bit, to explain what I think are their key complaints. In my view, there are two: the first is that the Coroner did not allow the family to give evidence, or question witnesses, about Zoe’s treatment by the Trust in the months leading up to her death; the second is that the Coroner did not properly consider whether Zoe’s death was a suicide. Those issues are connected but it is easier to look at each separately. [19]
It is clear that the Coroner decided to limit the scope of this inquest to the circumstances immediately surrounding Zoe’s death – namely, how she came to be found dead on the floor of her bedroom on 12 April 2021. He was not going to investigate whether there had been failings in Zoe’s care by the Trust, or look at whether any such failings might have contributed to Zoe’s death. [22]
C is dissatisfied with the Coroner’s decision to draw the inquest narrowly, and to answer the question about “how” she died question by reference only to the physical cause of death, rather than the circumstances which might have led up to that point. However, as a matter of law, the Coroner was entitled to narrow the scope of the inquest in that way. Indeed, most coroners would, I believe, have made a similar decision in these circumstances. The Coroner would have been concerned not to stray into an investigation into issues of civil liability which would breach the prohibition in section 10(2) of the 2009 Act. [23]
In summary, the Coroner was entitled to decide that issues relating to Zoe’s treatment by the Trust in the months before she died were outside the scope of the inquest and formed part of the background facts only. [25]
The central dispute appears to be whether Zoe was, or was not, actively planning suicide in the months before her death, on balance of probability. Active planning is different from merely considering suicide. [28]
it was reasonable, taking account of all the evidence before him, for the Coroner to conclude that Zoe’s death was drug-related… He was justified in not going further (to a suicide conclusion) because, taking all the evidence into account, he was not persuaded, on balance of probability, that she intended to kill herself. That was a rational and lawful position to take. [31]
There appears to have been a mismatch between the family’s expectations of what they could achieve at this inquest and the reality of the Coroner’s investigation which was much more limited in its scope. [50]
I am not persuaded that there is any reason to quash the Coroner’s conclusion and substitute suicide. The evidence for suicide is not clear-cut and drug-related death was a rational conclusion. I am not persuaded that it is necessary or desirable in the interests of justice for a fresh inquest to be ordered. I have not identified any substantial defect in the first inquest and I am satisfied that the inquiry which took place was sufficient as a matter of law. I would refuse this application. [51]
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