In the Matter of the Inquest into the Death of Robert Leech
[2023] EWHC 3476 (Admin)
HM Senior Coroner for Cornwall and the Scilly Isles
22 October 2024
[2024] EWHC 2673 (Admin)
High Court
Two hospital patients died after surgery. A later review found problems with the surgeon and the hospital. A judge agreed that new investigations are needed to figure out exactly what happened.
Key Facts
- •Two inquests, one into the death of Edward John Masters (2017) and one into the death of Mary Helen Rooker (2013), are challenged.
- •Both deceased were patients in the vascular surgery unit at Royal Cornwall Hospital.
- •New evidence emerged from a 2019 Royal College of Surgeons review, highlighting serious patient safety issues and shortcomings in multi-disciplinary processes.
- •The new evidence concerns potential shortcomings in the consent process, care, and treatment provided by a particular consultant vascular surgeon.
- •The applications are made under section 13 of the Coroners Act 1988, based on the discovery of new facts and evidence.
- •Interested parties (families of the deceased) support the applications.
Legal Principles
The interests of justice require a further inquest if fresh evidence reasonably leads to the conclusion that the substantial truth about the death was not revealed at the first inquest.
HM Attorney General v HM Coroner of South Yorkshire (West) [2012] EWHC 3783 (Admin)
Section 13 of the Coroners Act 1988 allows the High Court to quash an inquest and order a fresh investigation if, among other reasons, new facts or evidence make it necessary or desirable in the interests of justice.
Coroners Act 1988, section 13
Outcomes
The court allowed the claims.
The new evidence revealed significant shortcomings in the care and treatment, raising the possibility that the deaths were contributed to by unacceptable standards of treatment and care by the surgeon and deficiencies in hospital processes. The court deemed it necessary and desirable in the interests of justice to hold fresh investigations.
The court quashed the determinations and findings of the original inquests.
The original inquests were conducted with incomplete information. The new evidence warrants a fresh investigation.
The court directed that fresh investigations and inquests be held.
The interests of the bereaved and the public interest require a fresh investigation.
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