Rushbrooke v HM Coroner for West London [2020] EWHC 1612 (Admin) (23 June 2020)

This is an application by A, the daughter of Renee Rushbrooke (“Mrs Rushbrooke”), for an order quashing the determination and findings of an inquest held on 27 October 2016 into the death of her mother, and directing a fresh investigation and inquest be held. [1]

The application is made under section 13 of the Coroners Act 1988… [2]

…section 13 requires this court to answer a single question, namely whether the interests of justice make a further inquest either necessary or desirable… [3]

Mrs Rushbrooke was born on 8 October 1924. By 2016, she was unfortunately suffering from dementia, lacking mental capacity and was the subject of a Deprivation of Liberty Safeguards Standard Authorisation… [5]

Mrs Rushbrooke sadly died on 13 October 2016. The reporting doctor (Dr Pierre Berger) gave, as “Proposed cause of death”, “1a. Aspiration pneumonia. 1b. Stroke. 1l. Atrial fibrillation, dementia.”. No post-mortem was conducted. [9]

Because Mrs Rushbrooke had been the subject of a DoLS order at the time of her death, section 1 of the Coroners and Justice Act 2009 required that her death be reported to the coroner, and that he open an investigation and hold an inquest into her death. The inquest was held on 27 October 2016… the Coroner. He concluded that Mrs Rushbrooke died of natural causes, the medical cause of death being “1a aspirational pneumonia due to, 1b stroke, on a background of atrial defibrillation and dementia”. [10]

A was unhappy with the inquest. Her complaints lie under two broad and overlapping heads. First, she points to a number of procedural irregularities: the inquest was conducted under the DoLS fact-track procedure but neither she nor other family members were given the required notice of the inquest, they were not invited to make representations with regard to the scope of the inquest, they were not notified that it would be a paper-only inquest, and during the inquest A was (she submits) persistently interrupted by the Coroner which resulted in her being unable properly to give her evidence. Second, A complains that the investigation and inquiry conducted by the Coroner were insufficient. A had concerns about “stroke” being a cause of death: she was unaware of her mother having had a stroke, and any stroke she had had was certainly some years previously. A considered that the Coroner had failed properly to consider this issue, simply dismissing her concerns without giving any reason for doing so. Nor did the Coroner properly consider how the recent fractures were caused, and whether they caused or contributed to the death in circumstances in which (she submits) the enforced immobility caused by the fractures may have materially exacerbated Mrs Rushbrooke’s other medical conditions, including her breathing difficulties. The Coroner thus rejected and declined to hear relevant evidence. At the time of the inquest, and to the Coroner’s knowledge, a safeguarding investigation had been commenced; but no consideration was given to adjourning the inquest pending the outcome of that investigation. In all of the circumstances, the investigation and inquest were insufficient, and, she submits, the inquest should be quashed and an fresh investigation ordered. [11]

In response to the application, the Respondent frankly accepts that there is a real possibility that, for the reasons given in the claim, a fresh investigation and inquest may give rise to an alternative outcome. I agree. [12]

… it is clearly necessary and desirable in the interests of justice that a fresh inquest and investigation should take place. [13]