Shaw v HM Coroner for Leicester City & South Leicester (Mrs Catherine Mason)

JurisdictionEngland & Wales
JudgeLady Justice Hallett,Lord Justice Davis,Lord Justice Floyd
Judgment Date11 February 2014
Neutral Citation[2014] EWCA Civ 294
Docket NumberC1/2013/0826,Case No: C1/2013/0826 (A)(B)
CourtCourt of Appeal (Civil Division)
Date11 February 2014

[2014] EWCA Civ 294

Court of Appeal

Judges: Hallett, Davis and Floyd LJJ


R (Shaw)
HM Coroner for Leicester

Appearances: The appellant in person; A Sharland (instructed by Leicestershire City Council) for the Respondent; D Pittaway QC (instructed by Browne Jacobson) for the Hospital Trust; A Haycroft (instructed by Berrymans Lace Mawer) for the Interested Party.

Issue: Whether permission to appeal should be given to challenge the refusal to order a fresh inquest on the basis of alleged inadequacy of inquiry.

Facts: The appellant's elderly father had died in hospital following a relatively new surgical procedure that had been the subject of recent trials. At a 13-day inquest conducted so as to meet the State's investigative obligations under Art 2 ECHR the jury were asked to consider nearly 50 questions regarding his death. The jury's overall conclusion was that the death was an unintended outcome of a therapeutic medical procedure. The jury found that he was suitable for the procedure, was aware of the risks and had given informed consent.

The appellant sought a fresh inquest on a number of grounds including: delay; unlawful appointment of the Assistant Coroner; unlawful post-mortem examination; alleged bias by the Assistant Coroner; inadequacy of evidence; inadequacy of directions to the jury; failure to leave unlawful killing to the jury; and failure of the Senior Coroner to provide information to the appellant after the inquest. All the complaints were comprehensively dismissed by the Divisional Court ([2013] Inquest LR 10).

Permission to appeal on several grounds was then sought but refused on the papers, save for two grounds in respect of which an oral hearing for permission, followed by an appeal if necessary, was directed. These were: (1) the alleged failure of the Assistant Coroner to investigate the relevance of Ethics Committee documentation regarding efficacy of the device; and (2) the alleged failure to put these documents before the jury as they were relevant to informed consent and the suitability of the procedure for the elderly.


Hallett LJ:


1. The Applicant is the daughter of Mr William Ewan who died on 26 September 2007 at Glenfield Hospital Leicester aged 86. He was plainly much loved. Mrs Shaw wishes to appeal the Divisional Court's refusal to entertain her application for judicial review of the inquest into her father's death.

2. Mr Ewan died in the following circumstances: in 2007 he was diagnosed with a defective heart valve. He suffered from aortic valve stenosis, a progressive disease which can prove fatal. Treatment may be by open heart surgery, but that carries obvious risks for anybody, let alone the elderly. An alternative treatment was undertaken in Mr Ewan's case and it was relatively new in 2007. It has become known as TAVI, standing for Transaortic Valve Implantation. The procedure involves placing an artificial valve into the defective valve via a catheter in the femoral artery.

3. During 2007 Glenfield Hospital conducted a trial of the procedure. Mr Ewan's cardiologist, a Dr Fitzpatrick, referred Mr Ewan to Glenfield to see if there was anything they could do for him. Mr Ewan was seen by Dr Kovac, the specialist, on 12 June 2007. He underwent an angiogram on 28 June 2007.

4. On 25 September 2007, the Glenfield doctors having satisfied themselves that Mr Ewan was suitable for the TAVI procedure, he was admitted. The procedure was performed under general anesthetic. If Mr Ewan was not part of the TAVI trial, as Mrs Shaw believes he was, he was certainly one of the first patients at Glenfield to undergo TAVI after the trials had been concluded.

5. Shortly after the new valve had been fitted, Mr Ewan began to bleed from his aorta. It was decided to open his chest to determine the source of bleeding. Doctors did their best to stem the blood flow, and insert drains. Mr Ewan was then transferred to the intensive care unit, but, sadly, died not long after his arrival.

6. Over the next three and a quarter years up to the time of the inquest, an investigation took place into his death. Mrs Shaw would argue that that investigation was not sufficiently wide ranging and thorough. One of the reasons for the delay in holding the inquest itself was the backlog in work which confronted the Leicester City Coroner, Mrs Mason on her appointment. When she realized her other commitments would prevent her from conducting the inquest herself, she appointed a deputy, a Ms Casey to conduct the inquest. Ms Casey then had to stand down and another...

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