Lesley Ann Davison v HM Senior Coroner for Hertfordshire
| Jurisdiction | England & Wales |
| Judge | Lord Justice Holroyde,Mr Justice Garnham |
| Judgment Date | 15 September 2022 |
| Neutral Citation | [2022] EWHC 2343 (Admin) |
| Docket Number | Case No: CO/3685/2021 |
| Court | Queen's Bench Division (Administrative Court) |
[2022] EWHC 2343 (Admin)
Lord Justice Holroyde
Mr Justice Garnham
Case No: CO/3685/2021
IN THE HIGH COURT OF JUSTICE
KING'S BENCH DIVISION
ADMINISTRATIVE COURT
In the matter of an application under section 13 of Coroners Act 1988
Royal Courts of Justice
Strand, London, WC2A 2LL
Adam Straw KC (instructed by Irwin Mitchell) for the Claimant
Bridget Dolan KC (instructed by Hertfordshire Local Authority) for the Defendant
The Interested Party did not appear and was not represented
Hearing dates: 17 May 2022
Approved Judgment
This judgment was handed down by the judge remotely by circulation to the parties' representatives by email and release to The National Archives. The date and time for hand-down will be deemed to be Thursday 15th September 2022 at 11am.
Lord Justice Holroyde and
Megan Leanne Davison (“Megan”) had the misfortune to suffer from Type 1 diabetes and diabulimia, a psychiatric disorder which involves the deliberate omission of insulin doses. Very sadly, she took her own life on 4 August 2017, aged just 27. At an inquest held on 28 March 2018, HM Senior Coroner for Hertfordshire (“the Coroner”) concluded that Megan's death was suicide. He did not make a prevention of future deaths report (“PFD report”). By a claim issued on 11 October 2021, with the fiat of HM Attorney General, Megan's mother (“Mrs Davison”) applied for an order under section 13 of the Coroners Act 1988 quashing the Coroner's conclusion and directing a fresh investigation be held. At the conclusion of the hearing we announced that the application would be granted and a fresh inquest directed. We refused an application by Mrs Davison for an order that the Coroner pay some of her costs. We indicated that we would give our reasons in writing at a later date. We now do so in this judgment of the court.
Summary of key facts:
From late August 2016 until her death, Megan was under the care of the Community Eating Disorder Service (“CEDS”) at Hertfordshire Partnership University NHS Foundation Trust (“the Trust”). In September 2016 she took a potentially fatal overdose of insulin. She was subsequently detained under the Mental Health Act and admitted to an acute mental health unit. On two occasions in October 2016 she attended hospital suffering from diabetic ketoacidosis, a condition reflecting too low a level of insulin. In November 2016 she was admitted to an inpatient eating disorder service at a hospital. In January 2017 she left that hospital and took an overdose of insulin.
From March 2017 onwards, the treatment and management of Megan's eating disorder at CEDS was led by a psychological therapist, Ms Harris. In June 2017 Ms Harris, and other members of the CEDS team involved in Megan's care, were concerned that she might take her own life. On 8 June 2017 Megan was seen for the first time by Dr Sharma, a consultant psychiatrist at the Trust, who arranged a care plan. In mid-July Megan stopped taking her antidepressant medication and told one of her carers that there was no point living unless both her diabetes and her mental illness could be cured. Later that month she sent text messages to Ms Harris indicating that she wanted to end her life at Dignitas, but she was not able to do so.
On the morning of 4 August 2017 Megan sent a message to Ms Harris asking her to ensure that the emergency services, and not Megan's parents, would find her body. No immediate action was taken, but later that morning police officers went to Megan's home, where they found that she had hanged herself. She had left a note for her family.
The inquest:
Mrs Davison and her husband, and other members of Megan's family, attended the inquest. They were “interested persons” under section 47(2)(a) of the Coroners and Justice Act 2009. Mr and Mrs Davison had been sent, in advance of the inquest, a copy of the Hertfordshire Coroner Service Charter. That document set out standards of performance and customer care, but did not include any information about the way in which the Coroner would receive evidence. The interested persons did not know what witnesses were to be called until the inquest began.
In relation to Megan's care, the Coroner admitted into evidence part of a written statement by Ms Harris. He said that her statement was “very detailed and helpful” and indicated that he would read some portions of it together with the GP's history. Ms Harris therefore did not give oral evidence. Mrs Davison and her family did not know, and the Coroner did not tell them, of the right of an interested person to object to the admission of the written evidence.
No evidence, written or oral, was given by any other member of the CEDS team.
The only oral evidence heard by the Coroner was given by the police officer who found Megan's body and by Dr Sharma. Dr Sharma stated that he was not a specialist in eating disorders or diabetes, and had not previously encountered diabulimia. He understood that the combination of Type 1 diabetes and diabulimia was “quite a rare condition”. He also understood that there were no facilities to manage it and that the prognosis for those suffering from the disorder is poor. In answer to a question from a member of Megan's family as to whether Megan could have been treated in a different way if he had had a better understanding of diabulimia, Dr Sharma said that the CEDS team was in a better position than he was to manage Megan's condition.
The Coroner, as we have said, returned a conclusion of suicide. In explaining why he was sure that Megan had intended to end her life, he referred to diabulimia as “this terrible intractable eating disorder”. He said it was important to outline the context, and he therefore recorded that Megan —
“… had suffered for many years from type 1 diabetes and an eating disorder with bulimic patterns known as diabulimia.”
The Coroner explained why he would not make a PFD report. Unfortunately, a part of the recording was inaudible, and there are clearly some words missing from the transcript. It records the Coroner as saying –
“… it seems from the information that I provided that despite this being a rare condition, and one that is only starting to be understood, I do note – and it's from a BBC report – that a spokesman for NHS England, in fact the National Clinical Director for the Mental Health Team, told the BBC as recently towards September of last year that people are waking up to this condition [inaudible] involved in producing guidelines on eating disorders and debated a whole section on how you manage people who have got diabetes and an eating disorder. We are now disseminating that around the country. We have been asleep no doubt but we are waking up.”
The new evidence:
In July 2020 Mrs Davison sought the fiat of HM Attorney General to enable her to make this application to the High Court. HM Attorney General obtained a report from Professor Khalida Ismail, who is Professor of Psychiatry and Medicine at King's College, London, an honorary consultant psychiatrist and a leading expert in diabetes and diabulimia. Prof. Ismail properly disclosed that she had had some limited previous contact with Megan, though Megan had not been under her care
For present purposes, it is sufficient for us to summarise as follows some key points in Prof. Ismail's detailed report:
i) About 400,000 persons in the UK have Type 1 diabetes, and the incidence of the condition is increasing. Management of the condition includes the daily injection of insulin. Omission of insulin, whatever the reason, causes weight loss. It also activates ketosis, which can lead to ketoacidosis, with risk of death.
ii) Diabulimia is a psychiatric condition which causes sufferers to omit some or all of their insulin because of a fear that taking the insulin will cause an increase in weight. The condition is also referred to as T1DE: Type 1 diabetes with disordered eating.
iii) An estimated one-third of those with Type 1 diabetes omit some insulin for fear of weight gain. Diabulimia is therefore not a rare condition. Around 5–10% of those who omit some insulin are severe cases who would likely meet the criteria for diagnosis of an eating disorder. The more severe cases present most commonly with recurrent diabetic ketoacidosis. Those with severe diabulimia “are at very high risk of acute and chronic diabetes complications and premature mortality”.
iv) Healthcare professionals do not routinely screen for diabulimia or directly question patients as to whether they are omitting insulin.
v) Diabulimia and clinical depression often co-occur. It is therefore appropriate to integrate medical and psychiatric treatment. However, there is still a lack of awareness that those with Type 1 diabetes who also have mental health problems find it more difficult to manage their diabetes; and the differing health systems involved in caring for someone with multiple morbidities can lack knowledge of, and confidence in, one another. There is no pathway of care for diabulimia.
vi) The mortality rate for diabulimia is unacceptably high.
Prof. Ismail made a number of criticisms of the care which Megan had received, and expressed her opinion as to the potential value of a new inquest in increasing understanding of the nature and incidence of diabulimia, which could lead to more screening and assessment of patients and so reduce the number of deaths.
Having considered Prof. Ismail's report, the Attorney General authorised the making of this application.
The legal framework:
Section 13 of the Coroners Act 1988 (“s.13”) provides:
“ 13 Order to hold investigation.
(1) This section applies where, on an application by or under the authority of the...
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