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High Court rules that coroner should have resumed inquest into the death of a vulnerable woman killed by her daughter

The High Court has found that a coroner had applied the incorrect test in deciding not to resume a suspended inquest into the death of a woman, VB, killed by her daughter, K, and has ordered that a full inquest should be held.


1 November 2017

Yvonne Kestler, solicitor in the human rights department at law firm Leigh Day, represented VB’s son, MS, in his judicial review application challenging the coroner’s decision not to resume the inquest into the death of his mother.
VB was a person who had struggled with mental illness and alcohol problems over a lengthy period.  Over time it appeared that K was also suffering from some mental health problems, but K was reluctant to seek help from professionals.
The authorities and the health care services were aware of the risk posed by K, particularly to VB.
The police attended VB’s property in June 2012 after K was reported as smashing a glass table after being angry at VB but the police failed to investigate whether VB was at risk. In July 2012 K was reported as absent without leave after escaping from hospital. The police were told that K was very unwell and at risk of committing violence towards VB. In August 2012 K absconded from hospital again, the police were informed K was unwell and had assaulted a member of staff and that being in public meant that she “might do something”. The staff member said that she may be holding VB hostage.  Ward staff raised concerns regarding the potential wellbeing of VB and their staff. The police responded by saying that they would attend if K threatened staff.
On 16 August MS’s grandmother contacted the police raising her concern that she had not heard from VB for some days. The police gained entry to the house and found VB and K present. VB was deceased. K was arrested on suspicion of murder. At a plea and case management hearing K pleaded guilty to the manslaughter of her mother on the basis of diminished responsibility and was made the subject of a hospital order under the provisions of the Mental Health Act 1983.   
Following this incident, a Root Cause Analysis report was completed by Oxford Health NHS Foundation Trust and a Domestic Homicide Review (DHR) was undertaken. The DHR concluded that K’s low risk assessment was not consistent with her presentation and history and that although the homicide was not predictable, it was preventable.
The coroner concluded it was not necessary to hold an inquest as there had been a criminal trial where the facts had been adequately aired and two investigations into the circumstances of the death. This was incorrect as K had pleaded guilty before the case reached a trial and it was submitted that the two investigations into the circumstances of the death were not independent and did not satisfy the obligations under Article 2 of the European Convention on Human Rights – the right to life.
Article 2 inquests are held in cases where the State is deemed to have failed to protect the deceased and allows for an enhanced investigation by the coroner.
The court held that the coroner had referred to the incorrect test for resumption as being "whether the facts of the death [had] been adequately aired in public” when the test was whether "the senior coroner thinks that there is sufficient reason for resuming" a suspended investigation.
Further, the court found that on the facts of the case, the investigative duty required by Article 2 was clearly triggered. The coroner had referred to the "Crown Court trial" as well as the two reports as satisfying Article 2. However, there had not been a Crown Court trial and the investigations undertaken had been private. Taken together, they had not satisfied the requirements under Article 2.
Yvonne Kestler, solicitor in the human rights department, said:
“This claim was of importance to our client as he wanted to ensure that an independent, public investigation was undertaken into the circumstances surrounding his mother’s death, particularly in respect of the care provided to his sister.
“The judgment is of particular importance, not only to our client but to others, as it raises a significant point in respect of whether the Article 2 investigative duty can be complied with by internal investigations.”
Jude Bunting of Doughty Street Chambers was instructed.

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