R (Touche) v Inner London North Coroner
| Jurisdiction | England & Wales |
| Judge | LORD JUSTICE SIMON BROWN,LORD JUSTICE ROBERT WALKER,LORD JUSTICE KEENE |
| Judgment Date | 21 March 2001 |
| Neutral Citation | [2001] EWCA Civ 383 |
| Docket Number | Case No: C/2000/2479 |
| Court | Court of Appeal (Civil Division) |
| Date | 21 March 2001 |
[2001] EWCA Civ 383
Lord Justice Simon Brown
Lord Justice Robert Walker and
Lord Justice Keene
Case No: C/2000/2479
IN THE SUPREME COURT OF JUDICATURE
COURT OF APPEAL (CIVIL DIVISION)
ON APPEAL FROM THE DIVISIONAL COURT
LORD JUSTICE KENNEDY & MR JUSTICE MORRISON
Royal Courts of Justice
Strand, London, WC2A 2LL
Mr I. Burnett QC & Mr B. Collins (instructed by Hempsons of Manchester M2 3HR) for the Appellant
Mr P. Havers QC & Mr S. Taylor (instructed by Alexander Harris of London EC1N 2JT) for the Respondent
On 6 February 1999 Laura Touche gave birth to twins, delivered by caesarean section. On 15 February 1999, tragically, she died. She was only 3She died from a cerebral haemorrhage, the result of severe hypertension, possibly secondary to eclampsia. The medical evidence suggests that had her blood pressure been monitored in the immediate post-operative phase her death would probably have been avoided.
The critical issue raised in these proceedings is whether such a death is natural or unnatural whether, in particular, an inquest must be held into it pursuant to s.8(1) of the Coroner's Act 1988 which requires such an inquest "where there is reasonable cause to suspect that the deceased has died an unnatural death".
It is the coroner's contention that Mrs Touche died a natural death. Her husband contends the contrary. He is anxious for an inquest. The Divisional Court (Kennedy LJ and Morrison J) on 22 June 2000 accepted Mr Touche's argument and directed that an inquest be held. The coroner now appeals to this Court.
Perhaps not surprisingly the case has attracted some attention: the facts, after all, are heart-rending. The issue raised, however, is essentially one of law and its resolution cannot depend on sympathy.
With that brief introduction let me turn at once to set out such further facts as need be stated.
The facts
The deceased was delivered of healthy twins at about 10.25 p.m. on 6 February 1999 by caesarean section under spinal anaesthetic at the Portland Hospital in London. Her pregnancy and labour had been uncomplicated. Following delivery her blood pressure was noted to be 120/60 which was within normal bounds and at around 11 p.m. she was transferred to the postnatal ward. She was complaining of headache. The next note of her blood pressure was at 1.35 a.m. when it was recorded to be 190/100. By then her headache was severe and she was clearly unwell. Only at this stage did treatment begin and her blood pressure start to be taken regularly until finally it fell to normal limits. By then, however, it was too late. At 5.15 a.m. she was suffering a left-sided hemiplegia. At 6.15 a.m. she was transferred to the Middlesex Hospital and from there to the National Hospital for Neurology and Neurosurgery at Queen Square where eight days later, on 15 February, she died.
A hospital post-mortem examination, carried out by Professor Scaravilli on 18 February 1999, recorded the cause of death as:
"1a.
Brain swelling and tonsillar herniation
b.
Intra cerebral haemorrhage
2.
Recent pregnancy"
It was some months before Mr Touche's investigations into the circumstances of his wife's death led him to seek an inquest. On 28 July 1999 he wrote to the coroner referring to the 2 1/2 hour period between 11 p.m. and 1.30 a.m. when it appeared that Mrs Touche's blood pressure had not been monitored. On 26 August 1999 his solicitors wrote, alleging that "a basic, fundamental failure to record blood pressure readings vitiated any opportunity to avoid the catastrophic events which lead to Mrs Touche's death". On 15 September 1999 the solicitors wrote again saying:
"The Portland Hospital have already confirmed in writing to our client that a protocol does not exist to reflect the level of monitoring that should be given following a caesarean section. We have expert evidence to the effect that every NHS hospital in the country has a protocol in place for the care of patients in the post-operative phase in order to maintain standards within the hospital and ensure an appropriate level of patient care. It is disturbing that a private hospital with this reputation chooses not to adopt such a protocol."
On 31 August 1999 the solicitors obtained a report from Dr Bogod, an experienced consultant anaesthetist with a particular interest in obstetric anaesthesia. He was very critical of the lack of records relating to the periods during and after surgery. In particular he found the failure to monitor or record vital signs, including blood pressure, at a time when Mrs Touche was receiving pain relief "astonishing" and described the level of neglect as "starkly apparent".
The coroner himself took the trouble to obtain a report from Professor Rubin whose particular interest is in the medical aspects of pregnancy. His report of 29 February 2000 pointed out that maternal death in the United Kingdom is now "very rare" and described Mrs Touche's death as "extraordinary" because he has "looked after countless numbers of pregnant and post-partum women who have blood pressure in the range recorded in Mrs Touche [and] none has ever had a stroke".
The final report to which I must refer was obtained by Mr Touche's solicitors on 15 May 2000 by way of preliminary opinion from Dr Williams who runs a high-risk obstetrics service at the Chelsea and Westminster Hospital and who has a particular interest in pre-eclampsia. His essential conclusions were first that the failure to undertake blood pressure readings during the post-operative period involved "sub-standard practice", and second that the deceased's severe hypertension was responsible for her cerebral haemorrhage and that "it is likely that more prompt identification and treatment of her hypertension would have prevented her cerebral haemorrhage".
In short, the evidence as a whole provides clear grounds for suspecting that the Portland Hospital failed to monitor the deceased's blood pressure as it should have done in the critical post-operative phase and that such failure was an effective cause of her death in that, but for it, she would probably (or at least possibly) not have suffered cerebral haemorrhage and died.
S.8(1) provides:
"Where a coroner is informed that the body of a person (the deceased) is lying within his district and there is reasonable cause to suspect that the deceased -
(a) has died a violent or unnatural death;
(b) has died a sudden death of which the cause is unknown; or
(c) has died in prison or in such a place or in such circumstances as to require an inquest under any other Act, then, whether the cause of death arose within his district or not, the coroner shall as soon as practicable hold an inquest into the death of the deceased either with, or, subject to sub section (3) below, without a jury."
S.8(3) provides so far as relevant that the inquest must be held with a jury "if it appears to a coroner (d) that the death occurred in circumstances the continuance or possible recurrence of which is prejudicial to the health or safety of the public or any section of the public".
The issue arising
The central question to address is whether, in the light of the facts already summarised, there is reasonable cause to suspect that Mrs Touche died an unnatural death. I pose it in the present tense (and earlier summarised the evidence as it now stands) because the coroner's stance has remained the same throughout: whilst he "entirely accept[s] that the post operative monitoring would appear wholly inadequate", he does not regard the death as having been unnatural. He deposes as follows:
"I asked myself whether this was a case in which the defects and human fault complained of lifted the case out of the category of natural and into a category of unnatural death and, applying my commonsense as a coroner, I concluded that it did not."
In the ordinary way, of course, it is for the coroner to decide whether there is reasonable cause to suspect that a particular death is unnatural, and his decision will not be challengeable unless it is Wednesbury unreasonable or involves a self-misdirection in law. The facts here having now substantially crystallised, however, the point has been reached where really there can only be one correct answer to the central question and that answer must necessarily depend on what is meant in s.8(1) by "an unnatural death". Clearly there is reasonable cause to suspect that the circumstances of Mrs Touche's death are those indicated by the evidence already summarised. Assuming they are, is it properly to be regarded as an unnatural death? If so, subject to a single qualification to which I shall shortly return, the coroner has no alternative but to hold an inquest. If, however, the death is not to be regarded as unnatural he has no power to hold an inquest.
The ruling authority
The correct approach to take to the question whether there is reasonable cause to suspect that a deceased has died an unnatural death was decided by this court in R v Poplar Coroner ex parte Thomas [1993] QB 610. The deceased in that case died aged 17 from a severe attack of asthma. The evidence suggested that she would not have died had the ambulance which was called arrived promptly rather than after a thirty-three minute delay. The late arrival of the ambulance notwithstanding, this court concluded that the coroner had been entitled to regard the death as natural and so not hold an inquest. The leading judgment was given by Dillon LJ who at page 628 said this:
"Whether Miss...
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