Verdict following an inquest into the death of Raychel Ferguson
| Jurisdiction | Northern Ireland |
| Judge | Mr McCrisken |
| Judgment Date | 11 December 2023 |
| Neutral Citation | [2023] NICoroner 20 |
| Court | Coroners Court (NI) |
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Neutral Citation No: [2023] NICoroner 20
Judgment: approved by the court for handing down
(subject to editorial corrections) *
Ref: NICoroner 20
Delivered: 11/12/2023
IN THE CORONERS COURT FOR NORTHERN IRELAND
BEFORE CORONER J McCRISKEN
THE INQUEST TOUCHING UPON THE DEATH OF
RAYCHEL ZARA FERGUSON
__________
VERDICT FOLLOWING AN INQUEST INTO THE DEATH OF
RAYCHEL FERGUSON
___________
[1] Before I begin to deliver my verdict with respect to the death of
Raychel Ferguson, I want to give appropriate thanks to those Coroners Service,
Court Service and court security staff who assisted with preparations for this
inquest. I was represented by Coroners Counsel, Mr Chambers BL. My legal advisor
was Ms Laverty. For the Properly Interested Persons (PIPs), Ms Gallagher BL
appeared for the Western Health and Social Care Trust (‘the Trust’) instructed by
Ms Astbury, Solicitor, from the Directorate of Legal Services. Mr Boyle K.C appeared
for Nurse Noble, Nurse Gilchrist, Nurse McAuley, Nurse Roulston, Nurse Brice and
Nurse Kirk (‘the Nurses’) along with Mr Molloy BL, Ms Smyth BL and Ms Graham
BL instructed by the Royal College of Nursing. Mr Coyle BL appeared for Mr and
Mrs Ferguson (‘NoK’) instructed by Mr Doherty, Solicitor, of Elev8law.
[2] Whatever verdict I deliver here today, will not change the fact that Mr and
Mrs Ferguson lost their young daughter, Raychel, and their grief shall continue to
weigh heavily on them for the rest of their lives. This has been compounded by
knowing that Raychel’s death was avoidable. As outlined by O’Hara J, (as he is now)
in the Report of the Inquiry into Hyponatraemia-related Deaths (‘the Inquiry’),
errors were made by those charged with caring for Raychel. Lessons that should
have been learnt following the death of Adam Strain and Lucy Crawford were not.
The Ferguson family have spent the last 22 years attending various legal hearings
and fighting to get answers which they deserve to have.
[3] This verdict must be read in conjunction with the Inquiry Report. At the
outset, I agreed to admit the entirety of the Inquiry Report pursuant to Rule 17 of the
Coroners (Practice and Procedure) Rules (Northern Ireland) 1963 (‘the 1963 Rules’).
This allowed not just those factual matters already established following the Inquiry,
but also those conclusions reached by the Inquiry, to be considered during the
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inquest. My verdict, therefore, borrows heavily from those factual matters contained
within the Inquiry Report.
[4] I also considered expert reports provided to the Inquiry, and heard oral
evidence, from the following witnesses:
1. Dr Haynes
2. Dr Makar
3. Nurse Noble
4. Nurse Gilchrist
5. Nurse McAuley
6. Nurse Roulston
7. Nurse Bryce
8. Nurse Kirk
9. Mr Zafar
10. Dr Crean
11. Mr Fulton
12. Dr Curran
13. Dr Gilliland
14. Mr and Mrs Ferguson
Relevant law
[5] Rule 15 of the 1963 Rules governs those matters to which inquests shall be
directed and provides that:
“The proceedings and evidence of an inquest shall be
directed solely to ascertaining the following matters,
namely:
(a) Who the deceased was;
(b) How, when and where the deceased came by his
death;
(c) … The particulars for the time being required by
the Births and Deaths Registration (Northern
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Ireland) Order 1976 to be registered concerning the
death.” [My emphasis]
[6] Rule 16 goes on to say that:
“Neither the Coroner nor the jury shall express any
opinion on questions of civil or criminal liability …”
shall be protected by law.” It is established law that this provision has a substantive
aspect, governing the ways in which the state should act to protect life, and a
procedural aspect, which imposes an obligation on the state to provide for
investigation as to whether a death may have resulted from a breach of the
substantive obligations imposed by article 2. The precise content of the substantive
obligations and of the procedural obligation under article 2 varies depending on the
circumstances of a particular death.
[8] In Northern Ireland, it is established law that, where necessary, to avoid a
breach of any Convention rights (within the meaning of the Human Rights Act
1998), the purpose mentioned in Rule 15(b) (above) is to be read as including the
purpose of ascertaining how and in what circumstances the deceased came by their
death. An expanded verdict may be required to satisfy the procedural requirement
of article 2, including, for example, a conclusion on the events leading up to the
death, or on relevant procedures connected with the death. In practice, in a
non-article 2 inquest, a verdict should be a brief, neutral, factual statement; it should
not express any judgment or opinion. By contrast, a verdict in an article 2 inquest,
known as an expanded verdict, may be judgmental.
Relevant Law
[9] In the case of R (Morahan) v HM Assistant Coroner for West London [2021]
EWHC 1603 (Admin) (‘Morahan’), Popplewell LJ set out the distinct article 2 duties
imposed on ECHR States.
“(1) There is a negative duty to refrain from taking life
without justification (see, for example, Rabone v Pennine
Care NHS Foundation Trust [2012] 2 AC 72 at paras 12
and 93). This arises not only at a state level but more
commonly, in practice, at an operational level, and
includes cases where an individual dies at the hands of an
agent of the state, such as a police shooting. This may be
labelled the negative operational duty.
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