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In the recently reported case of

R (on the application of JOHN DUFFY) (Claimant) v HM DEPUTY CORONER FOR WORCESTERSHIRE (Defendant) & WORCESTERSHIRE ACUTE HOSPITALS TRUST (Interested Party) (2013) [2013] EWHC 1654 (Admin) the Admin Court, on an application for judicial review of a verdict of death by natural causes, quashed the verdict and ordered a fresh inquest.  T was aged 14 months and died in hospital. He was brought to hospital with bronchial problems. Doctors failed to see that the X-ray showed an enlarged heart. He was given dextrose and just over 3 litres of fluids. He suffered a cardio-respiratory arrest and died. A Report produced following an investigation disclosed fluid intake as possibly having contributed to the cardio-respiratory arrest. The Coroner heard from only two witnesses at the Inquest; the pathologist and a former consultant paediatric cardiologist [S]. S’s evidence was crucial to the verdict; fine 

judgement in relation to causation was called for. He said that those treating T had failed to identify that he had a heart condition and metabolic acidosis. He criticised the Doctors for not correcting the metabolic acidosis and not using inotropic drugs. He was not able to go as far as saying if these two failings had been corrected that on the balance of probabilities T would have survived. Although the Deputy Coroner described Dr S as not having been on a children’s ward for “some little time” S had not been involved with intensive care of children for some 15 years. Although S said that careful and measured management of fluids for an infant in T’s case was necessary he was also unable to say whether T had received an appropriate or inappropriate amount of fluids. The claimant then sought an adjournment of the Inquest for an up to date expert could be instructed. This was refused.

Perhaps not surprisingly it was held that the Inquest had raised very serious questions about the level of medical care T had received.  S’s evidence gave rise to real concern and it was held that the Coroner had not given due weight to his lack of involvement in intensive care of children for 15 years. His lack of up to date experience  raised a question about the strength of his conclusion about causation.. He had been unable to deal with questions about the appropriate level of fluids to be administered to an infant of T’s age and weight.  Fluid intake had been identified as a contributory cause of T’s death in the investigation report. The Court held this was not satisfactory. that the deputy coroner had made material errors and she had also reached a conclusion which, on the balance of relevant factors, was not reasonably open to her and risked causing substantial injustice.  The Court held in paragraph 39 of the judgment that there was a material procedural irregularity, the verdict could not stand and must be quashed..

 Practitoners in the field will appreciate that Expert’s reports commissioned by Coroners can be a tricky issue. We have experience of such reports either being served late with pretty scant account of previous relevant experience or in one case no written report at all before a hearing. It is not clear from this judgment why this was not covered in a written report from Dr S before the hearing or why the properly interested parties did not seek their own expert evidence from a more up to date expert in the field as to the likely impact of 3 litres of fluid intake by T in this case to present at the hearing. Whatever the reasons for issues not being dealt with beforehand this case is useful for practitioners who seek adequate disclosure of Coroner’s expert’s reports in advance of full Inquests or indeed during the course of an inquest where a Coroner’s expert discloses surprise evidence or a lack of up to date expertise in their stated field which cannot be remedied at the hearing itself.