R Mrs Fatmire Gorani v HM Assistant Coroner for Inner West London

Hearing dates: 18 May 2022

Approved Judgment

I direct that pursuant to CPR PD 39A para 6.1 no official shorthand note shall be taken of this Judgment and that copies of this version as handed down may be treated as authentic.

Lady Justice Macur AND Mr Justice Garnham

Introduction

On 19 December 2018 Mr Besim Sylaj fell to his death from the fifth floor balcony of his home in Westbourne Grove in London. Mrs Fatmire Gorani, the widow of the deceased and the Claimant in these proceedings, brings this claim for judicial review, challenging the conduct, findings and conclusion of the defendant, the Assistant Coroner for Inner West London, (hereafter “the Coroner”) at the inquest into the death of her husband. The Central and North West London NHS Foundation Trust, (“the NHS Trust”), which was the health authority responsible for Mr Sylaj's medical care, and Dr Samantha Sanghera, a locum GP at his GP practice, are Interested Parties.

The coroner is a judicial office holder. The normal course for a judge or other judicial office-holder facing a judicial review is to adopt a neutral stance in the proceedings and to appear, if at all, not as a party to defend her decisions, but simply to offer the court her assistance on matters of procedure or specialist caselaw. By contrast, the Coroner here has not only appeared by counsel to oppose the application, but has submitted a witness statement in support of her case. A coroner who choses to enter the arena in this way puts herself at risk of a costs order against her should the claim succeed (see R (Davis) (No 2) v HM Deputy Coroner for Birmingham[2004] 1 WLR 2739 at [47(ii)]).

I have approached the coroner's witness statement with a little caution. When allegations of bias are made, as they are here, a court may consider the explanation of the judge (or coroner); see R (Pounder) v HM Deputy Coroner for the North and South Districts of Durham and Darlington[2010] EWHC 328 (Admin), at [12]. But the coroner's witness statement does not address the question of bias. Instead, she seeks to explain her reasoning and to respond to the grant of permission to bring the proceedings. A coroner's reasoning ought to be apparent from her decision. The court would only resort to some ex post facto explanation if the circumstances made that essential (compare R (D) v Secretary of State for the Home Department[2003] EWHC155 (Admin) at [18]). It has not been necessary to have regard to the coroner's statement in this case.

Mrs Gorani was represented before us by Mr Philip Rule. The defendant coroner was represented by Mr Jonathan Landau and the second interested party by Ms Elaena Misra. The first interested party did not appear and was not represented before us. I am grateful to all counsel for their submissions.

The Statutory Scheme

S.5 of the Coroners and Justice Act 2009 (“the 2009 Act”) sets out the purposes of an inquest:

(1) The purpose of an investigation under this Part into a person's death is to ascertain—

(a) who the deceased was;

(b) how, when and where the deceased came by his or her death;

(c) the particulars (if any) required by the 1953 Act to be registered concerning the death.

(2) Where necessary in order to avoid a breach of any Convention rights (within the meaning of the Human Rights Act 1998 (c. 42)), the purpose mentioned in subsection (1)(b) is to be read as including the purpose of ascertaining in what circumstances the deceased came by his or her death.

(3) Neither the senior coroner conducting an investigation under this Part into a person's death nor the jury (if there is one) may express any opinion on any matter other than—

(a) the questions mentioned in subsection (1)(a) and (b) (read with subsection (2) where applicable);

(b) the particulars mentioned in subsection (1)(c)…

Paragraph 7 of schedule 5 to the 2009 Act provides for the making of reports after an inquest:

(1) Where—

(a) a senior coroner has been conducting an investigation under this Part into a person's death,

(b) anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and

(c) in the coroner's opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances,

the coroner must report the matter to a person who the coroner believes may have power to take such action.

(2) A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it.

(3) A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner.

The Facts

Much of this history is taken from an agreed chronology prepared by the parties.

Prior to his death on 19 ^th December 2018, the deceased lived in his family home in Westbourne Grove with his wife, the claimant, and their three daughters. In March 2017, he was diagnosed by his GP as suffering from depression, for which he was prescribed antidepressants (Citalopram 20mg once daily).

On 23 February 2018, the deceased's GP, Dr Patel, referred him to the emergency mental health team at St Mary's Hospital where he was prescribed further antidepressants (Mirtazapine, in addition to Zopiclone already prescribed). The GP recorded him as unfit to attend work.

On 27 ^th February 2018, the deceased attempted to take his own life by overdose (15 Mirtazapine tablets and 5 Zopiclone tablets). An ambulance was called by his family and he was taken to St Mary's Hospital, where he was assessed by the “Crisis Team”.

On 28 ^th February 2018, Dr Philip Nwachuku recorded the deceased as having told him that “ he had felt low in mood and anxious and panic and had the sudden thought of killing himself. He had thought of wanting to jump from a height but then said it may be easier to die from OD.” The deceased was assessed by the Crisis Team at St Mary's and discharged home under the care of the North Kensington Home Treatment Team (‘HTT’). He was given a 24-hour helpline to contact.

Initially, the HTT attended his home on a twice daily basis and his wife and daughters were with him 24-hours-a-day. On 5 March 2018, the HTT visits reduced to once daily; by mid-March 2018, they had reduced to every other day.

On 3 April 2018, care responsibility was transferred from the HTT to the deceased's GP and HTT involvement ceased. The deceased remained unfit to work and was continuing to receive prescription treatment by way of anti-depressants (Mirtazapine) and sleeping pills. During a consultation in July 2018, he was observed by his GP to be “ slightly overactive” and his Mirtazapine dose was reduced to 30mg daily. Referral was made to the GP based counselling service “Community Living Well” (“CLW”).

On 17 April Mr Sylaj saw his GP about stress at work, anxiety and sleep difficulties. Dr Patel suggested he referred himself to primary mental health services for psychology services, which he did.

On 11 July Mr Sylaj attended an appointment with CLW. He was discharged from the service and there was no further contact after that day.

Between September and December 2018, the deceased reported increased anxiety and distress due to disciplinary proceedings against him at work. He was reviewed by his GP on 14 September 2018, but was offered no other assistance.

On 6 December 2018, Mr Sylaj was seen by Dr Patel. He complained of feeling tired and reported a loss of appetite. His mood was “ up and down”. Dr Patel booked a follow-up appointment for a fortnight later, 20 December.

The following day, 7 December, the deceased's employers began disciplinary investigation against him.

On 12 December, Mr Sylaj's family were concerned about the deterioration in his mental health and phoned the NHS Trust's “Single Point of Access” (SPA). The call was not triaged by a clinician as it should have been according to the SPA policy. Mr Sylaj was advised to attend the Accident & Emergency department, but was unwilling to do so.

On 13 December, Mr Sylaj attended an emergency GP appointment with Dr Sanghera, who agreed to refer him to the Mental Health Team, “ for further psychotherapy”. She also planned to increase his anti-depressant medication. Ultimately, however, no referral was ever made and no change to his medication was put into effect. Dr Sanghera, however, did write to Mr Sylaj's employers.

On 14 ^th December 2018, the deceased attended a disciplinary meeting at work and was dismissed.

On 19 ^th December 2018, the deceased, who was then aged 50, jumped to his death from the balcony of his family's fifth floor home.

The Inquest Procedure

The inquest into the deceased's death was opened on 24 ^th December 2018.

A number of pre-inquest reviews were conducted. On 12 December 2019, following written and oral submissions as to the applicability of Article 2ECHR, the Coroner determined that Article 2 did not apply. She summarised her reasons for that decision in a later ruling:

It was my...