R (Takoushis) v HM Coroner for Inner North London and Others
| Jurisdiction | England & Wales |
| Judgment Date | 16 December 2004 |
| Neutral Citation | [2004] EWHC 2922 (Admin) |
| Date | 16 December 2004 |
| Court | Queen's Bench Division (Administrative Court) |
[2004] EWHC 2922 (Admin)
Court and Reference: Administrative Court, CO/2727/2004
Elias J
R Brander (instructed by Scott-Moncrieff Harbour and Sinclair) for the claimant; I Daniels (instructed by Guys & St Thomas' Hospital Trust) for an interested party. The coroner did not appear and was not represented.
Whether a jury ought to have been summoned and expert evidence heard in respect of the adequacy of a system which failed to prevent a psychiatric patient absconding from hospital and killing himself.
The deceased, the claimant's husband, had a long history of psychiatric treatment for schizophrenia. When he was a voluntary psychiatric in-patient he left the hospital and was found preparing to jump off Tower Bridge. The police were called and the deceased mentioned that he was taking anti-psychotic medication but not that he was currently an in-patient. He was persuaded to go to a nearby hospital's A&E department voluntarily.
That A&E department had a system for assessing psychiatric patients under which the deceased was categorized as needing to see a doctor within ten minutes. A psychiatrist did not attend for an hour, by which time the deceased, who had been left unattended, had left the hospital. His body was subsequently found in the Thames.
At an internal investigation it was noted that it was common for p atients attending A&E following an attempted suicide to abscond. As a consequence of the incident the procedures adopted by the Trust were changed such that security staff would now provide supervision until the assessment was made.
At the inquest the coroner refused a request to summon a jury on the basis of s. 8(3) Coroners Act 1988 as he found the circumstances were not likely to recur. He also refused a request to adjourn the inquest to allow the claimant opportunity to seek expert medical evidence in relation to the adequacy of the hospital policies governing the deceased's treatment. T he coroner rejected the suggestion that there had been any evidence of system neglect, stating that the circumstances of the particular delay arose as an individual episode, he was satisfied that there was a reasonable system in place for voluntary patients at risk of self-harm and the fact that the standard had been improved did not prove that the original system was unreasonable . He returned a verdict of suicide.
The claimant sought an order quashing the inquest on the grounds that (1) the coroner erred in law by refusing to hold the inquest with a jury; (2) the inquiry was inadequate because of the refusal to hear expert evidence in relation to the standard of care.
Introduction
1. This is an application for judicial review. It arises out of the inquest into the death of a 64-year-old-man, whose body was found in the river Thames on 14 February 2003. There are essentially 2 grounds to the claim:
the coroner erred in law by refusing to hold the inquest with a jury; and / or
the inquiry at the inquest was inadequate because the defendant refused to allow the claimant the opportunity to call expert evidence in relation to the care the deceased received from the Guy's and St Thomas' NHS Trust (the interested party) immediately prior to his death.
2. The claimant seeks an order quashing the inquest which was formally opened on the 24 February 2003, was resumed on 3 March 2004 and continued on the 4 March. She also seeks an order that a fresh inquest be held with a jury.
3. The claimant and the interested party have been represented before me by Ms Brander and Mr Daniels respectively. I am grateful to them both for the quality of their submissions. The coroner was not represented. He has, however, helpfully provided a witness statement for the assistance of the court.
The facts
4. The deceased, Pavlos Takoushis, was the husband of the claimant. He was a long-term schizophrenic who had been treated periodically in psychiatric hospitals, both voluntarily and involuntarily, since he was first diagnosed with the illness in 1974.
5. On 9 January 2003 he was admitted to Chase Farm Hospital as a voluntary patient. On 13 January, at approximately 11.15am, Mr Takoushis obtained permission to leave the ward to visit the day hospital within the hospital grounds. He did not return.
6. He was next seen at about midday apparently preparing to jump off Tower Bridge. He had his legs over the parapet of the bridge and he was being pulled back from the edge by an American tourist. This was witnessed by a member of the public who was passing, Mr Jeff Wilcox. Mr Wilcox was concerned by Mr Takoushis' behaviour and decided to follow him. After Mr Takoushis had made several more approaches towards the river edge, Mr Wilcox decided to call the emergency services.
7. Police arrived, followed by an ambulance crew. Mr Wilcox told the officers what he had seen. Another officer, PC Prole, spoke to Mr Takoushis and suggested that he go to hospital. Mr Takoushis agreed. PC Prole stated in his evidence at the inquest that he was concerned about Mr Takoushis' safety at that point and had Mr Takoushis not agreed to go to the hospital voluntarily, he would have considered his powers to detain him and remove him to a place of safety under s. 136 of the Mental Health Act 1983. In the event, however, he did not need to use this power.
8. Mr Takoushis informed one of the other officers present that he was taking a drug for his illness. (He apparently said that it was "Promazone" but presumably meant Promazine, a low-potency anti-psychotic medication.) He did not, however, mention that he was currently an in-patient at the Chase Farm Hospital.
9. Mr Takoushis was then taken by ambulance to St Thomas' Hospital Accident and Emergency Department. The information regarding Mr Takoushis' medication was not passed on to the ambulance crew.
10. Mr Takoushis arrived at St Thomas' A&E at about 13.00hrs. The ambulance staff explained to a staff nurse Blake, who was the triage nurse on duty at that time, that Mr Takoushis had been found trying to jump off Tower Bridge. Nurse Blake took Mr Takoushis to a cubicle used for patients with potential mental health problems.
11. The Trust has a system in place for assessing the needs of psychiatric patients who present themselves at the A&E department. This was based on a document termed the Manchester Triage Mental Health Flowchart. It involves the clinical prioritisation of patients including those with mental health problems.
12. In this case Nurse Blake triaged Mr Takoushis as being category 2 (to be seen by a doctor within 10 minutes). This is the most urgent category possible for a psychiatric patient unless he or she has in addition sustained life-threatening physical trauma, requiring, for example, immediate resuscitation. She also recorded that he was at "high risk of self harm".
13. Nurse Blake then contacted a psychiatric liaison nurse, who stated that Mr Takoushis would have to be seen by a medical doctor before she could attend to him. This was in accordance with the protocol then in place. At about 13.35hrs, Nurse Blake handed over to a colleague, Elaine Brown.
14. It appears that Mr Takoushis was then left alone in his cubicle until 13.55hrs, when he was offered an analgesic. At 14.00hrs, a Dr Fritz, attended to see Mr Takoushis, but he was nowhere to be found. Unfortunately this was almost an hour after the patient's arrival, well beyond the 10 minutes envisaged by the system.
15. Just before 15.00hrs, an office worker at St Katherine's Way saw a man jump into the Thames at St Katherine's Dock. Her description of the man fitted that of Mr Takoushis. His body was recovered some 5 weeks later, on the 14 February, from the River Thames at Wapping.
The relevant law
16. The circumstances in which a coroner is obliged to summon a jury are identified in the Coroners Act 1988. They include cases of death in prison or in police custody. The relevant provision in issue here is s. 8(3)(d) which provides:
"If it appears to a coroner, either before he proceeds to hold an inquest or in the course of an inquest begun without a jury, that there is reason to suspect -
(d) that the...
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