Nguyen v HM Assistant Coroner for Inner West London [2021] EWHC 3354 (Admin) (10 December 2021)

This is an application by C brought under s. 13 of the Coroners Act 1988 pursuant to the fiat of HM Solicitor General granted on 26h April 2021 for the quashing of the inquisition into the death of his son. [1]

The circumstances in which he died were recorded by the Assistant Coroner as follows: “At 7:30pm on 24/08/16, Hayden attended the emergency department in Chelsea and Westminster Hospital. He was treated for sepsis with antibiotics and admitted. Following a worsening of his condition he was moved to the high dependency unit where he suffered a cardiac arrest at about 6am. Despite advanced life support resuscitation it was not possible to restore circulation and he was pronounced life extinct at 7:15am on 25/8/16.” [2]

The challenge to this inquisition is brought on three distinct grounds: … (2) There is new evidence that justifies re-opening the inquisition… [3]

[Ground 2] The factors militating in favour of holding another investigation are as follows. First, the forensic weaknesses in the SUI report would be significantly weakened if there were evidence, as there now is, that earlier invasive procedures would on the balance of probabilities have led to [son’s] survival. Secondly, although I would not go so far as to hold that the Assistant Coroner demonstrated apparent bias in her conduct of these proceedings, some of her questioning… came close to the borderline between robustness and unacceptability. Thirdly, the Trust has now admitted liability in civil proceedings, at the very least calling into question the Assistant Coroner’s narrative conclusions in this case. Fourthly, even if the administrative error which led to Dr Conway’s report not being made available to Dr Martin does not generate a free-standing ground of challenge, it is relevant to the separate issue of whether it would be desirable in the interests of justice for Dr Martin to have the opportunity to take on board his views and, indeed, the similar views of Dr Playfor. Fifthly, the further evidence lends new insights into the issue of causation which it would be desirable to balance against the opinion of Dr Martin. Finally, in a case of this sensitivity and importance to the family, and taking into account the interests of the Trust, the treating clinicians and the public, it is desirable that the Coroner receive further evidence from apparently independent sources on the issues of standard of care and causation. No doubt that evidence will be thoroughly tested before the Coroner, but it deserves to be considered. [105]

it would be desirable in the interests of justice for a further investigation to be held in this case. Ground 2 therefore succeeds [106]