Coroners and Inquests

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1 Coroners and Inquests Information for clients attending Inquests head and shoulders above the rest in terms of skills, experience and quality. The Legal 500 Inquests Freephone

2 Introduction 2 Contents Introduction Case study: Positive verdict at inquiry Case study: Death while under the care of the NHS The Inquest: Before, during and after the Inquest Case study: Early settlement acheived Meet the team Front image: The seal of Richard I, the Lion Heart, in whose reign the office of Coroner was formally established (1194) Coroners, Inquests and Public Inquiries At Field Fisher Waterhouse we have been dealing with unexpected and unnatural deaths for over 20 years I m Andrew Morgan, a partner in our leading personal injury team. I have been specialising in mesothelioma and asbestos disease claims for nearly 20 years. Over the same period my partners and colleagues have acted for the families of those killed in accidents at work, on the roads and railways, or as a result of medical negligence or accident. Perhaps as many as one in three families will be affected in some way by an inquest we may each have to provide some information or attend as a witness or we might have known someone struck down by tragedy as a colleague, friend or family member. A few of us will sit on the jury at an Inquest that is heard in public. It is so important for families to understand what caused the death and, where possible, to call those responsible to account. That is where we come in. We can help by guiding you through the Inquest process, by representing you when you need it and by claiming compensation where we can - money is no answer to sudden bereavement but neither is it acceptable for families to suffer the double injustice of financial loss when that can be avoided. Whatever brings you into contact with the Coroner, as a relative or a witness, I hope this short guide will help you understand when and why an Inquest might be needed, what you might be able to achieve through the Inquest and how we can help you, before during and after the process. If you want to discuss a recent bereavement, or want more information about Coroners and Inquests, or about making a claim, please call me on or

3 Case Study Freephone Case study Verdict of Death by Misadventure following self-amputation of leg 3 Mark Bowman represented Susan Hepburn at an inquest into the circumstances of her husband s death. Mr Hepburn, aged 65, died in August 2010 after severing his right leg with a hacksaw. 10 years previous he was paralysed from the waist down after being shot by a neighbour. Since that time, Mr Hepburn had increasingly found his legs to hinder his mobility, preventing him from independently getting in and out of his car for example. Mr Hepburn, who had a history of impulsive behaviour, was unable to find a surgeon willing to amputate his legs, and so he started to research the possibility of selfamputation on the internet. We were able to secure the verdict of death by misadventure Mr Hepburn decided to begin the procedure himself in the hope that once he had called an ambulance, the treating medics would complete the rest of the operation. Unfortunately, having started the amputation and then calling 999, the paramedics were unable to reach Mr Hepburn in time and he was pronounced dead at the scene. It was paramount to Mrs Hepburn that she ensured her husband was not found to have committed suicide as this was not his intention. We were able to secure the verdict of death by misadventure that was so important to the family. Thank you very much for all your invaluable help, professionalism and kindness and I will always remember you as being instrumental in making this devastating time in my life a little easier. Thank you. Susan Hepburn Caring for our clients Commitment to our cases Cutting edge expertise

4 4 A big thank you for all your efforts and hard work! Your support and encouragement has meant so much and helped me to press forward with the claim. Thank you so much! Deborah Higgs

5 Case Study Freephone Case study Inquest into death while under the care of the NHS 5 Edwina Rawson acted for Deborah Higgs following the death of her daughter, Crystal, who was aged 21. We represented Deborah at an inquest that took place in March 2011 in preparation for a possible claim for compensation for Crystal s son. Crystal had a history of mental health problems, and was admitted to the psychiatric ward of Edgware Hospital for treatment. Crystal had been under the care of Barnet, Enfield and Haringey Mental Health NHS Trust, which is responsible for Edgware Hospital. In July 2006, Crystal went with a nurse to a shop outside the hospital grounds. The nurse was inappropriately junior to be caring on her own for a patient with Crystal s condition. At the shop, Crystal was put in a situation where she was able to abscond. She got on a bus, went to Brent Cross Shopping Centre, and tragically jumped to her death from the top of the multi-storey car park. Shortly before the inquest, the hospital admitted that the care it provided it had been sub-standard in allowing an inexperienced nurse to accompany Crystal on her own. The nurse should not have let her leave the shop on her own. If she had stayed with Crystal she would probably not have absconded, therefore preventing her death. The Inquest heard that the nurse should have ensured that Crystal was in eyesight. It also emerged that staff had neither recorded nor shared with colleagues their knowledge that Crystal had been having suicidal thoughts in the days before they agreed to let her go to the shop. Further, there was a delay in alerting the police that Crystal had gone missing, even though she had attempted suicide before. Naturally, the family were apprehensive about the inquest A police officer told the inquest that if they had been informed earlier, they would have sent a patrol car to Brent Cross as Crystal had made her way to this location on a previous occasion. On that earlier occasion, a security guard had managed to talk her into coming down. Naturally, the family were apprehensive about the inquest, but it answered many of their questions. The verdict of the jury was that a breakdown in communication could have resulted in relevant information not being made available during the decision-making process and this could have been a factor in preventing her death. Caring for our clients Commitment to our cases Cutting edge expertise

6 6 The Inquest Jonathan Zimmern explains what happens before, during and after the Inquest Coroners have been with us in one form or another since the 12th Century. Over the centuries Coroners have exercised many powers on behalf of the Crown, mainly relating to taxation and declarations of treasure trove. But even since those earliest times the Coroner has had the responsibility of establishing the cause of any unexplained death, wherever there may have been a breach of the King s peace. Over time the role has evolved, and it continues to evolve, but the system in place today is broadly the same as that established by The Coroners Act of 1887

7 The Legal process Freephone Why an Inquest? In England and Wales the Coroner will hold an Inquest when he is notified of a death that was violent or unnatural or, in the case of a sudden death, where the cause is unknown. The Coroner will not investigate all deaths. However death resulting from an industrial disease such as the asbestos cancer mesothelioma is deemed unnatural and in most cases the Coroner will begin ( open ) an Inquest of his own accord. Sometimes the Coroner and the family will disagree as to whether an Inquest should be opened. In some cases it is possible to 1challenge a Coroner s decision not to hold an Inquest. The family may be able to influence the question that the coroner asks or the evidence that he calls for. This is where legal representation can be very helpful. Post Mortem Medical Examination It is almost always the case that a Coroner who opens an Inquest will require a post-mortem examination. The main exception is when the deceased was suffering from a welldiagnosed and advanced terminal condition. In most cases a post mortem will help establish the cause of death. This could be relevant to any compensation claim. It may be possible to obtain a post-mortem report at private expense if the Coroner has not already done so. 3 7 Timescale Some Inquests can be concluded within a few weeks. If a Hearing is needed then this will probably take place a few months after the death, but each case is different. There may be delay if someone has been charged with a criminal offence in connection with the death (e.g. murder/manslaughter). 2 Asbestos Related Deaths A post-mortem examination can provide new and unexpected medical information about the cause of death. That information may be relevant to any compensation claim. If a claim has already begun or has been contemplated then it is essential that the Defendant (the person or company against who the claim is made) is informed of the death and is given the Coroner s details as a matter of urgency. If the Defendant is not given the opportunity to obtain and safeguard relevant medical information then the civil court might not 4allow any compensation claim to be made at all. This is especially true where lung cancer is involved. Caring for our clients Commitment to our cases Cutting edge expertise

8 8 Death Certificates A death certificate will not normally be granted until the Inquest is finalised, although an interim certificate of the fact of death will normally be issued within a few days of the death. This certificate should be accepted by banks, insurers, the Benefits Agency and others as proof of death so that bank accounts can be accessed, life insurance payments can be requested, direct debit payments for utilities and insurance be terminated and so on. 5 The Funeral The funeral may be held once the Coroner releases the body. The Coroner will normally allow burial or cremation once the examination of the body is complete, within a few days of the death, even though the Inquest process has only just begun. 6 Who s at Fault? It is not the Coroner s role to establish who was at fault. Instead it is the Coroner s role simply to establish what happened and to give his verdict accordingly. The Coroner can give a short form verdict or a narrative verdict Possible short form verdicts are: neglect unlawful killing suicide attempted/self-induced abortion accident/misadventure natural causes industrial disease want of attention at birth drugs dependency open verdict lawful killing After hearing the evidence, the coroner will give the jury a summary of the evidence and will tell them what verdicts are available in the light of that evidence. The jury will then deliver its verdict. Sometimes the Coroner will give a verdict himself. A coroner may choose to give a narrative verdict in which he will provide a clear and concise statement of events. This will be phrased neutrally but often provides more information than simply giving one of the short-form verdicts. When there is a Jury the coroner may invite them to answer factual questions. If the inquest shows that something could be done to prevent other deaths, the coroner may report this to the relevant organisation that has the 7power to take action. This is referred to as a Rule 43 Report

9 The Legal process Freephone Will there be a Public Hearing? In some cases the Coroner will conduct an Inquest on the papers without a public hearing if he is satisfied about the medical cause of death and the surrounding circumstances. For example, where someone has died in a hospice after suffering for a period from the asbestos cancer of mesothelioma then the Coroner might enter a verdict of Death by Industrial Disease without any hearing and perhaps without any Post Mortem examination. 8 Media Coverage All inquests must be held in public and someone from the press might be present in court. The coroner will make every effort to treat the family sympathetically and will often not read out personal notes or letters or display other sensitive evidence unless it is essential. The Coroner may warn the family before such evidence is produced to allow them to withdraw if they wish. In some cases the person, company or organisation who is said to have caused the death might be present. They might give evidence. They may be represented by lawyers. 10 In some instances the family may want to publicise the inquest, and it is possible to prepare a press statement to give to journalists. 9 Representation at a Hearing Representation by lawyers at a hearing might raise issues or might uncover evidence which is valuable to the family. This might simply help the family understand what has happened. It might help avert similar deaths in the future. It might help in a later compensation claim. Public funding ( Legal Aid )is not generally available to cover representation at the inquest but there are exceptions. The costs of paying for representation may be recoverable if a later civil claim for damages is successful. We might act on a no win no fee basis for the family or we might arrange pro bono (i.e. free) representation 9 Conclusion Although the Coroner does not say who is at fault, any verdict might be useful in a subsequent compensation claim - it might confirm a medical issue, or it may shed some light on facts surrounding the death that may not have surfaced otherwise. For the family the Inquest may provide the first and possibly last opportunity to ask the right questions and to get some answers that will help them come to terms with what has happened. 11 Caring for our clients Commitment to our cases Cutting edge expertise

10 Case study 10 Case study Early mesothelioma settlement acheived for bereaved family Leonard Richley was employed by Mather & Platt from about 1948 until about His job involved installing fire prevention systems in department stores, factories and similar premises. He also worked for Mather & Platt in at least one power station. In this employment he was exposed to asbestos. Mather & Platt were once part of a huge industrial empire but they ceased to trade in about 1995 and went into liquidation in Sadly, as a result of this asbestos exposure, Mr Richley developed the asbestos cancer, mesothelioma, from which he died. Because it was caused by asbestos exposure at work Mr Richley s death was referred to the Coroner who ordered an inquest. It was only at this point that his daughter, Angela Humphrey, learnt that the family may be entitled to make a claim. Andrew was able to trace an employee of the company Angela instructed Andrew Morgan at Field Fisher Waterhouse, to bring a mesothelioma claim against her father s employer, Mather & Platt Limited. Andrew was able to trace a number of related companies using information from the company s liquidator and from Companies House. In this way he identified insurers who might be liable to pay for a successful claim even though the company no longer existed. Unfortunately, Mr Richley did not make any statement before he died - he was not aware that he was suffering from an asbestos related condition until the very last few days of his life. But Andrew was able to trace an employee of the company who worked alongside Mr Richley and who was able to give a detailed statement to support the mesothelioma claim. Andrew issued Court proceedings in the Mesothelioma Fast Track in the Royal Courts of Justice in London and obtained Judgment and an Order for an interim payment of 47,000. The Court set an Assessment Hearing date to assess the value of the claim but Andrew negotiated a settlement of 75,150, the full value of the claim, before the Hearing. Angela was happy to accept this offer and the case was completed in under 10 months. I would like to thank you for your hard work and for such a quick outcome of the claim. You have made the process nice and easy. It wasn t as daunting as I thought. Angela Humphrey

11 The Team Freephone Meet the team Our team act on a no win, no fee basis. 11 Andrew Morgan Partner Edwina Rawson Partner Mark Bowman Senior Associate Andrew has specialised in cases involving industrial diseases, including asbestos diseases, since He is a past Coordinator of the Occupational Health Group of the Association of Personal Injury Lawyers (APIL) and is an APIL Fellow. He advises the Parliamentary Sub- Committee on Asbestos. Edwina is a partner in our medical negligence team. She is on the Law Society s clinical negligence panel and is a member of the Association of Personal Injury Lawyers (APIL). Edwina gives regular presentations to Association against Medical Accidents (AvMA) and APIL. Mark pursues cases on behalf of victims of medical negligence. A member of the Law Society clinical negligence panel, Mark is also a Senior Litigator at the Association of Personal Injury Lawyers (APIL). Jonathan Zimmern Associate A barrister, Jonathan acts for those injured through negligence or accidents. Jonathan is a member of the Association of Personal Injury Lawyers (APIL) and a volunteer on the AvMA helpline. Dushal Mehta Solicitor Dushal specialises in asbestos disease cases with specific expertise in mesothelioma claims. He joined the firm in 2009 and is a member of the Association of Personal Injury Lawyers (APIL). He has developed a reputation for securing early settlement in high profile cases. Clients praise the very strong relationships they forge with the lawyers, with one even stating: They understood what I meant better than I did! Chambers UK, 2012 A leading Legal Directory Caring for our clients Commitment to our cases Cutting edge expertise

12 Freephone Vine Street, London, EC3N 2PX Ibex House, The Minories, London, EC3N 1HP Postal address: PO Box 732, London, EC3N 2AA Coroners an Caring for our clients Commitment to our cases Cutting edge

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