The Queen (on the application of John Paul Chidlow) v HM Senior Coroner for Blackpool and Fylde
| Jurisdiction | England & Wales |
| Judge | Mr Justice Pepperall,Lord Justice Hickinbottom |
| Judgment Date | 12 March 2019 |
| Neutral Citation | [2019] EWHC 581 (Admin) |
| Court | Queen's Bench Division (Administrative Court) |
| Docket Number | Case No: CO/2002/2018,CO/2002/2018 |
| Date | 12 March 2019 |
and
[2019] EWHC 581 (Admin)
THE RIGHT HON. Lord Justice Hickinbottom
THE HON. Mr Justice Pepperall
Case No: CO/2002/2018
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
ADMINISTRATIVE COURT IN MANCHESTER
DIVSIONAL COURT
Manchester Civil & Family Justice Centre
1 Bridge Street West, Manchester M60 9DJ
Ifeanyi Odogwu (instructed by Broudie Jackson Canter) for the Claimant
Alison Hewitt (instructed by Sefton Council) for the Defendant
There being no appearance by the First Interested Party
Ana Samuel (instructed by the North West Ambulance Service NHS Trust) for the Second Interested Party
Hearing date: 26 February 2019
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.
Carl Bibby fell ill in the night of 27/28 July 2009. An ambulance was called but there was admitted delay in the response of the North West Ambulance Service NHS Trust (NWAS). During that delay, Mr Bibby suffered cardiac arrest and died. He was only 38.
At the inquest in respect of his death, the jury heard evidence from a consultant in Critical Care & Emergency Medicine that had paramedics attended Mr Bibby before he suffered cardiac arrest, he would, on the balance of probabilities, have survived. Nevertheless, the coroner ruled that it was not safe to leave the issue of a causal link between the delay and Mr Bibby's death to the jury. By these judicial review proceedings, Mr Bibby's brother, John Chidlow, seeks a declaration that the coroner acted unlawfully, an order quashing the record of inquest and an order that a fresh inquest be held before a different coroner.
THE FACTS
MR BIBBY'S DEATH
On the evening of 27 July 2009, a neighbour heard banging and screaming inside Mr Bibby's home in the Kirkby area of Liverpool. She called the police who arrived at the scene shortly before midnight. A police officer saw Mr Bibby lying on the floor in his flat and called the police control room in order to request an ambulance. The first call to NWAS was made at 23:54. The police reported that a male was threatening suicide and was lying on the floor within his property. This call was graded with the amber code 25B06. This signified that the patient was believed to be suicidal and called for a bravo-level response.
At 00:03 on 28 July, the police forcibly entered Mr Bibby's flat. They found him lying on his back with his head titled back. They noted that his complexion was grey, his breathing laboured and his pulse fast. At 00:10, the police made a second call to the ambulance service notifying them that Mr Bibby was now fitting. This information was logged, but the case was not re-prioritised.
By 00:30, police officers noted that Mr Bibby's breathing remained laboured and that he was grey in colour. Limb restraints were used as Mr Bibby was pushing back. A few minutes later, Mr Bibby made a last gasp and then stopped breathing. The officers recorded that his body went limp.
At 00:36, a police officer called NWAS again. The case was initially upgraded to 25D01. While still an amber code, the upgraded delta-level response would allow the call handler to dispatch a rapid response vehicle. The police explained that the patient was not breathing and that he was unconscious. The case was then upgraded to 09E01, a purple code which signifies that the patient is in cardiac arrest. It is the highest possible priority and required an 8-minute vehicle response.
At 00:38, the police called again. They asked when the ambulance would arrive and explained that Mr Bibby was now in cardiac arrest. The four police officers carried Mr Bibby through to his lounge and started cardiopulmonary resuscitation while they waited for the ambulance. A fifth call was made to NWAS at 00:42 when the police said that the patient was neither conscious nor breathing.
The first ambulance arrived at the scene at 00:46. On arrival, paramedics found that Mr Bibby was asystolic (i.e. there was no electrical activity from his heart), his pupils were fixed and he was not breathing. Further resuscitation was hopeless and Mr Bibby was certified dead at the scene at 00:47.
John Kilroe, an Emergency Control Centre Training & Development Manager for the Cheshire and Merseyside Area of NWAS, made a statement although he had retired by the time of the inquest. A colleague therefore gave evidence confirming Mr Kilroe's evidence. Mr Kilroe asserted that the initial call had been correctly graded, but that the failure to upgrade the case in response to the call at 00:10 had been an error. Mr Kilroe explained, at paragraph 9 of his statement:
“I can confirm that call number two was incorrectly coded as the Emergency Medical Dispatcher who took the call should have re-prioritised the case to reflect the patient's clinical deterioration (patient was now fitting). If this had been recoded it would have been prioritised as a red 8-minute vehicle response.”
Mr Kilroe then considered the resources available to NWAS on the evening of 27/28 July 2009 and concluded that, had the second call at 00:10 been properly coded with an 8-minute vehicle response time, a rapid response vehicle would have been available and would have arrived at Mr Bibby's flat at approximately 00:20. The ambulance therefore arrived some 51 minutes after the original emergency call to NWAS and 36 minutes after the second call at 00:10 which, on Mr Kilroe's evidence, should have led to the urgent dispatch of a rapid response vehicle.
THE INQUEST
The inquest in respect of Mr Bibby's death was heard by HM Senior Coroner for Blackpool and Fylde, Alan Wilson, and a jury between 12 and 22 February 2018. It is a matter of concern that the inquest was so badly delayed. In fairness to Mr Wilson, I should, however, observe that the case was originally to be heard by another coroner. A challenge to the first coroner's conduct of the inquest led to earlier judicial review proceedings, thereby causing inevitable delay and leading to that coroner's decision to recuse himself in June 2017.
Medical evidence
The jury heard that post-mortem examinations conducted by Dr Gradwell on 28 July 2009 and Dr Richard Shepherd, a Home Office pathologist, on 3 August 2009 failed to establish a medical cause of death. There was also a separate examination of Mr Bibby's heart by Dr Mary Sheppard, a consultant cardiac pathologist. She also found nothing remarkable but raised the possibility of an electrical abnormality such as a channelopathy and noted that alcohol withdrawal can cause cardiac arrythmia and fitting.
Two further pathologists, Dr Brian Rodgers and Dr Nathaniel Cary, were instructed for the purposes of the inquest. Each reported and, after discussion of the evidence, Drs Shepherd, Rodgers and Cary agreed that the cause of death was unascertained. They specifically agreed that there was no evidence of any natural disease, that a sudden cardiac event such as a channelopathy was unlikely and that there was no evidence of any toxicological cause of death. By their joint report, they added:
“The history suggests that the deceased may have been suffering from an acute behavioural disturbance. If it is accepted that the deceased was a chronic alcoholic then the finding of a minimal blood alcohol level raises the possibility that the deceased was suffering from acute withdrawal. This might explain his acute behavioural disturbance.”
Dr Shepherd recorded that Mr Bibby was a known alcoholic and that there were some changes in his liver that would accord with alcohol abuse.
In his report, Dr Cary considered the possibility of a link between struggling against restraint and death. He reported:
“In cases of this kind there are many factors believed to underline the development of cardiac arrest. Position, including being prone and restriction of breathing through pressure on the chest and indirectly on the abdomen through being in contact with the ground are not the only potential factors that operate. Equally important is the effect of prolonged struggling, which is often akin to isometric exercise where muscles expend energy but there is little if any movement. Prolonged struggling against restraint and the extreme levels of exercise that it may entail has a strong potential to cause lactic acidosis and muscle breakdown known as rhabdomyolysis. The latter can be associated with acute elevations in potassium which of itself has a negative effect on the heart. In these circumstances cardiac arrest is likely to occur as a result of the combined effects of several factors including lactic acidosis, the possibility of a raised potassium level and hypoxia from restriction of breathing as a result of the restraint itself. Hypoxia may develop quite suddenly and be the final feature prior to collapse.”
In their joint report, the three pathologists agreed:
“Any potential role for struggling and restraint in causing or contributing to death will be dependent on evidence adduced at the inquest. At present the circumstantial evidence is somewhat vague and contradictory and until a clearer picture emerges, we feel unable to comment either way.”
Dr Cary returned to this theme in his oral evidence. The coroner summarised his evidence to the jury that it was “both possible and plausible” that restraint or struggling against restraint was the major cause of death or at least provided a more than minimal contribution. He added that Dr Cary acknowledged that the evidence of a link between restraint or struggling against restraint and death fell short...
To continue reading
Request your trial
-
B50 v HM Asst Coroner for E Riding of Yorkshire and Kingston Upon Hull
...the approach to “ Galbraith plus” adopted by Haddon-Cave J: see [39]. In R (Chidlow) v HM Senior Coroner for Blackpool and Fylde [2019] EWHC 581 (Admin), Pepperall J (with whom Hickinbottom J agreed) referred to Haddon-Cave's formulation and added, at [35]: “In many cases, there may be lit......
-
R (Wandsworth Borough Council) v Senior Coroner for Inner West London
...or finding, then it is likely to follow that the jury could reach it safely: R (Chidlow) v HM Senior Coroner for Blackpool and Fylde[2019] EWHC 581 (Admin), [2019] Inquest LR 93. Where, as in the present case, there is no jury, the coroner will naturally consider the safety of any conclusio......
-
R Carole Smith v HM Assistant Coroner for North West Wales
...Counsel for the Claimant accepted that this was the right question for the Coroner to answer. 59 She referred to R (Chidlow) v HM Senior Coroner for Blackpool and Fylde [2019] EWHC 581 (Admin), a case in which the Divisional Court quoted the Tainton summary of the law on the threshold and ......
-
Wandsworth Borough Council v HM Senior Coroner for Inner West London
...or finding, then it is likely to follow that the jury could reach it safely: R (Chidlow) v HM Senior Coroner for Blackpool and Fylde [2019] EWHC 581 (Admin). Where, as in the present case, there is no jury, the coroner will naturally consider the safety of any conclusion or finding he or s......