Mary Patricia Farrell v HM Coroner for North East Hampshire

Hearing date: 24 March 2021

Approved Judgment

Introduction

Ray Farrell died on 24 October 2016, aged 53. He was suffering from malignant mesothelioma as a result of exposure to asbestos as a fitter's mate in his early working life. Mr Bradley, then senior coroner for North East Hampshire, held an inquest on 27 October 2016 and recorded the cause of death as mesothelioma. Ray's mother, Mrs Farrell, applies with the fiat of the Attorney General for the determination to be quashed and for a fresh inquest to take place, on the grounds that there should be an investigation of whether Ray's wife, Ms Burden, hastened his death by deliberately giving him inappropriate medication, motivated by personal financial gain. No such suggestion was raised with the coroner at the time.

Narrative

The following matters are established by contemporaneous documents or are not in dispute.

In 1979 Ray left school aged 16 and spent a short time as a fitter's mate under the Youth Training Scheme with Oxoid Ltd. It was there that he was exposed to asbestos fibres. He went on to have a career as an electrician.

In January 2008 he met Ms Burden and shortly thereafter they started a relationship. She worked and lived in London during the week. He lived in Overton, Hampshire. They spent much of their leisure time together.

On 15 October 2010 Ray was diagnosed with epithelioid mesothelioma. On 13 January 2011 he had a right pleurectomy/decortication operation. The histology from the removed material confirmed the diagnosis. Ray was given a prognosis of 6 months life expectancy and stopped work. He chose not to tell his children, Kyle and Kelly, or his friends about his disease. Until his death, only his parents and Ms Burden knew of his diagnosis, together with Ms Burden's family and one of their closest friends in order to provide her with support.

Ray underwent a course of six cycles of chemotherapy. In 2011 he commenced a civil claim against Oxoid Ltd (by now Unipath Management Ltd), which was settled in January 2013 for about £375,000. Between October 2013 and January 2014 he was given a further six cycles of chemotherapy. Between September 2014 and October 2015 he took part in a placebo controlled trial of a new type of immunotherapy treatment. Not long after its completion he experienced greater pain and the cancer progressed.

On 22 January 2016, Ray and Ms Burden saw Dr Bartlett, a GP at Ray's local practice in Overton, to discuss their getting married at home. On 25 January 2016 Dr Bartlett wrote:

“I am writing to confirm the following points with regards to the proposed marriage of the above-named patient.

a I am the doctor in medical attendance on the above-named patient.

b The above-named patient is seriously ill and not expected to recover.

c The above-named patient cannot be moved to a place registered for marriage.

d The above-named patient understands the nature and purpose of marriage.

…”

The following day Ray was suffering from constant discomfort which he described as like a weight on his chest and he had a tachycardia. The GP had him admitted to Basingstoke Hospital, where he remained until 29 January 2016.

On 2 February 2016 Ray and Ms Burden were married at his home in Overton in the presence of his parents. I will return to the disputed account of events on that day from Mrs Farrell and Ms Burden.

Ray's medical notes record that on 8 February 2016 he was refusing to be readmitted to hospital as an inpatient and was awaiting a hospice bed, with home oxygen to be arranged in the meantime; and that on 9 February 2016 he was admitted to St Michael's Hospice, clinically in congestive heart failure with uncontrolled rate. His cardiology stabilised over the following days and he was discharged from the hospice on 18 February 2016.

Although on 12 July 2016 Ray's treating consultant oncologist at Guy's Hospital, Dr Spicer, had written to a colleague in Lille asking that he consider Ray for a medical trial if he were suitable, in a letter to Dr Bartlett of 8 September 2016 Professor (formerly Dr) Spicer described a consultation with Ray and Ms Burden on 19 August 2016 at which there had been an explicit understanding reached in the course of a conversation about the various options that “the time for aggressive anti-cancer measures may have passed, and certainly Ray is aware that his primary focus currently is on ensuring symptom control.” This is in line with a letter of 10 August 2016 from Dr Steele, a consultant medical oncologist from Bart's Hospital who saw Ray as a follow up to the drugs trial and observed that he seemed to have become much thinner and weaker.

Ray's condition worsened. On 3 October 2016 he had a cordotomy at Portsmouth hospital, and was discharged the following day. The next day, 5 October 2016, Ray and Ms Burden attended a consultation with Dr Emilia Moretto, a local consultant in palliative care. Dr Moretto's letter of 7 October 2016 to Dr Rial, another GP at the local Overton practice, recorded that Ray was extremely fatigued and had very little balance. The letter went on to say: “We discussed that he was very poorly, and that as there had been such a change in such a few days my feeling is that prognosis is very short, possibly weeks or maybe days….. I will re-refer him to hospice at home service and they will visit him at home on 6/10/16. We will also check his just in case medications. He would like to die at home if at all possible – and I reassured him that we would endeavour to support him and his family to do this…..” The letter also said: “As discussed on the telephone, he has voiced before that he had hoped he would not require a post-mortem. We do not have his histology, but Dr Riley [sic, presumably a typographical error for Dr Rial] was going to discuss with coroner pre-emptively to see that if he has detailed histology, I presume from London, he might not require a post-mortem. We did not discuss this at the appointment today.”

No doubt prompted by this letter, on 10 October 2016 Dr Rial contacted Mr Bradley by phone. The medical notes made by Dr Rial record that he told Mr Bradley that it was Ray's wish that there be no post-mortem. As Mr Bradley explained in subsequent correspondence, he was told that Ray had been diagnosed with mesothelioma some years before and that biopsies had been performed with the results available to him to confirm. Although he was required to conduct an inquest because mesothelioma was an industrial disease, it was his usual practice to proceed without a post-mortem where there was a confirmed diagnosis and the patient was attended in his final illness. Mr Bradley's contemporaneous note of the conversation records that he said he would be happy to proceed to an inquest without a post-mortem examination if the histology results were in order.

On 10 October 2016 Mrs Farrell arranged for a Catholic priest to administer the Last Sacrament to Ray.

On 13 October 2016 Dr Moretto phoned Dr Phillips at the GP surgery to say that she had found the histology results and would forward them. Dr Phillips emailed Dr Pollard (being another GP at the practice) asking her to forward them to Mr Bradley, which Dr Pollard did the following day. Dr Phillips asked Dr Pollard to amend Ray's out of hours paperwork to reflect the discussions Dr Rial had had with Mr Bradley, so that all that would be necessary when Ray died would be for a doctor to verify death, following which the body could be taken to an undertaker, and for the coroner to be notified the next day if it happened overnight. The medical notes record Dr Philips saying: “I hope this is clear – I just wanted it documented asap as he's deteriorating rapidly.”

On 18 October 2016 Dr Moretto visited Ray's home for a consultation with him and Ms Burden. Also present was a woman from the hospice at home service. Dr Moretto's letter to the GP the following day recorded that she had found Ray to remain extremely weak and that he had not eaten for a week. He had accepted a hospital bed which was awaited, but was reluctant to accept care. The letter described Ray's clinical symptoms and said: “I still feel time is very short” and “I think his prognosis is probably a short number of days”.

Ray died at home in his bed in the early hours of 24 October 2016. Ms Burden's account is that he went to sleep at 2300 and she next checked on him around 0130 and found that he had died. She rang Ms Farrell to tell her, and Mrs Farrell came over to the house with her husband. Ms Burden telephoned the out of hours GP service at 0140, and again at 0155. Mrs Farrell's account was that they were at the house when Ms Burden was on the phone to the GP. Dr Tighe attended at 0330 and confirmed the death, which he recorded as “expected”. His summary of the case notes recorded that Ray had had advanced metastatic mesothelioma with multiple lung and abdominal metastases and ascites, and had been...