C seeks judicial review of D’s findings of fact and conclusion at the end of the inquest into the death of her 12-year-old daughter, V, dated 10 April 2024. [1]
IP to the claim is the Trust responsible for the Royal Manchester Children’s Hospital (“the RMCH”), where V died on 15 July 2019. [2]
V died, having suffered a sickle cell crisis, in circumstances where the RCMH has accepted that there were some failings in her care. [3]
C advanced three grounds of review. Ground 1 related to D’s approach to the alleged failings in care by the RCMH. Ground 2 relating to his approach to causation. Ground 3 ultimately became an argument about the materiality of any errors identified under Grounds 1 or 2. C seeks a quashing of the Record of Inquest and D’s written reasons, leading to a fresh inquest. [4]
After V’s death an inquest was opened. V’s family and the Trust were IPs in the coronial proceedings. There was no suggestion that the procedural obligations under Article 2 of the European Convention on Human Rights applied to the investigation. It was accepted that the scope of the inquest would include the issue of whether there had been any failure to provide timely and appropriate medical care to Victoria and the likely causative impact of any failure to provide her with appropriate treatment. [30]
the medical cause of her death as being “1a. Cerebrovascular Accident [due to] 1b. Arterial ischaemia [due to] 1c. Sickle cell disease”. There is no challenge to this conclusion. [39]
D recorded the following: “The Deceased, who suffered from sickle cell disease, was admitted to North Manchester General Hospital on 1st July 2019 and was thought to be in sickle crisis. On 2nd July 2019 she was transferred to Royal Manchester Children’s Hospital for ongoing care.
On 5th July 2019, the Deceased developed sudden onset of vomiting and severe headaches. The Deceased’s headache persisted for three days, and on the morning of 8th July 2019 she suffered two seizures. Radiology confirmed ischaemic brain injury, and the Deceased was subsequently transferred to the Paediatric Intensive Care Unit. On 9th July the Deceased underwent an exchange transfusion, and a CT scan demonstrated widespread cerebral infarction.
The Deceased met the criteria for brain stem death following testing on 12th July 2019, and she died at Royal Manchester Children’s Hospital on 15th July 2019″. [40]
the conclusion as to the cause of death… a short-form conclusion of “natural causes”. [41]
D concluded the findings of fact and conclusion as follows:
“21. In summary, my findings are as follows:
a. There was a failure in Victoria’s care on the evening of 5 July 2019 and morning of 6 July 2019 is not processing to imaging (CT and MRI scans) when it was clear that Victoria was suffering serious neurological symptomatology;
b. Had imaging been undertaken on 6 July 2019, this would not have conclusively confirmed the presence of subarachnoid blood;
c. Thus, save for a change in the course of Victoria’s care with imaging on 6 July 2019, no other substantive changes would have been implemented;
d. Imaging that was undertaken on 8 July 2019 did not reveal evidence of subarachnoid blood on the balance of probabilities, although the appropriate sequencing for the MRI scan was not requested;
e. On the balance of probabilities, there is insufficient evidence to state that Victoria would have avoided the terminal event on 8 July 2019 which caused her death on 15 July 2019.
22. Flowing from my findings, in my judgment Victoria has died from a naturally occurring illness, which sadly reached its natural end on 15 July 2019. Whilst I have found failures in her care, none of these failures more than minimally contributed to her death on the balance of probabilities. As a matter of law, the factual circumstances of Victoria’s death fits squarely within the legal definition of ‘Natural Causes’, and therefore I will return this as a short-form conclusion”. [50]
the claim is dismissed [157]
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