Smith, R (On the Application Of) v Assistant Coroner for North West Wales [2020] EWHC 781 (Admin) (07 April 2020)

application for judicial review of a Coroner’s decision and Record of Inquest [1]

Five issues are raised for Judicial Review, which claim:

i) The decision erred in law as to the threshold for causation of death.

ii) The decision erred in law as to the standard of proof for causation of death.

iii) The decision was irrational in its failure to accept the evidence of an expert, Dr Maganty, about causation of death.

iv) The decision and Record of Inquest were not compliant with the requirements of an investigation under Article 2 of the European Convention on Human Rights.

v) The decision was irrational in failing to make a finding of neglect. [3]

Leah was born in 1989 and died at the age of 27 on 2 May 2017. [5]

In March 2017… she was noted by her partner and the GP as suffering from a sudden onset of paranoid delusions. [6]

At a home visit on 17 April Leah’s mental health had become worse, but she denied thoughts of self-harm. [17]

Leah took an overdose of co-codamol later in the day (17 April 2017), in the context of paranoid delusional thinking. [18]

Leah was admitted to hospital. She was scored at the top end of ‘medium’ on a suicide intent scale at the hospital. An on-call psychiatrist was consulted. It was decided to discharge her to the Home Treatment Team and increase her risperidone prescription to 2mg a day. [19]

Leah was discharged from hospital on 19 April. She was seen at home and it was agreed that someone would always be with her in the next few days. [20]

On 25 April 2017 Leah was seen for the first, and only, time face-to-face by a psychiatrist in consultation. He took detailed notes. These include “sometimes fears not worth living”; “Her mood and verbal communication have deteriorated”. His conclusion was: “Impression – first episode of psychosis. Plan – refer to early intervention team, start mirtazapine 15mg nocte, reduce the dose of risperidone by 1mg every 3 days and stop, start olanzapine 5mg nocte after the 1mg risperidone bd stops. Review if required by the home treatment team.” [23]

On 28 April 2017 Leah hanged herself… [25]

Dr Maganty’s Report [commissioned by coroner] reached the following conclusion: “Considering all the above, i.e. failure of provision of basic medical care, in my opinion, on the balance of probabilities, the death of Miss Leah Smith was not only predictable but was entirely preventable…” [33]

the “Conclusion of the Coroner as to the death”, was: “The deceased hung herself with a ligature on 28/4/17. This act caused her death. At the time she took this action it is likely that she was suffering from an episode of psychosis of unknown origin.” [51]

The relief claimed… is: “Replacement of all or part of sections 3 and/or 4 of the Record of Inquest with a narrative that refers to the failings in care provided by the [Interested Party] to Ms Smith.” [52]

the Coroner was entering into her actual finding of fact… which was that [the conduct] did not have “any evidential causative effect”. We see no basis in her reasoning, either of fact or law, for overturning that conclusion. [63]

We reject the suggestion that Dr Maganty… was entitled to have his opinion accepted by the Coroner. She did a good job of exploring and taking into account all the evidence, as we can see from the transcripts of the hearing as well as from her Reasons. The conclusion she reached was rational and securely based on the whole of her careful evidential enquiry. [70]

unless the alleged neglect was causative of the death, a finding of neglect could not be included. We have upheld the Coroner’s findings about causation. [85]

The application for judicial review is dismissed… [86]