In the recent judgment of Davison v HM Senior Coroner for Hertfordshire, The Administrative Court has quashed the previous decision of a Senior Coroner and determined that a fresh inquest should take place in relation to the death of a young woman suffering from Diabulimia.
Case background
The Deceased, a 27- year old teacher, suffered from Type 1 Diabetes and Diabulimia (a highly dangerous psychiatric disorder involving the deliberate omission of insulin doses). The Deceased was under the care of the Community Eating Disorder Service and a Consultant Psychiatrist at Hertfordshire Partnership University NHS Foundation Trust.
The Deceased was sadly found hanged in her home on 4 August 2017. An inquest subsequently took place in March 2018 to determine where, when, and how she died. The Senior Coroner for Hertfordshire concluded that this was a death by suicide. A Prevention of Future Deaths (PFD) Report was not made.
The Deceased’s mother (Claimant) subsequently brought a High Court challenge seeking a fresh inquest into her daughter’s death on the basis that new expert evidence on Diabulimia showed there was a public interest in more being known about the dangerous condition and there was real possibility of a PFD report being made based on the evidence of systemic issues around the treatment of this “poorly understood” disorder which has an “unacceptably high” mortality rate.
High Court decision
The Administrative Court allowed the Claimant’s challenge for an order under Section 13 of the Coroners Act 1988, to quash the Defendant Coroner’s conclusion that the Deceased had taken her own life.
The Court held that the discovery of new evidence, primarily a report by an expert in Diabulimia, meant that it was necessary and desirable in the interests of justice for a fresh investigation to be held by a different coroner.
In this case, it was found that the Coroner had proceeded with the investigation on the basis that Diabulimia was a rare condition. However, the expert evidence makes clear that it was in fact a widespread condition. It was reported that approximately 400,000 people in the UK have Type 1 diabetes and that an estimated one-third omit some insulin doses due to a fear of weight gain.
It, therefore, became apparent from the expert’s evidence that there was a public interest in more being known about Diabulimia, particularly as the report indicated that:
- The condition was more widespread than commonly recognised;
- Better co-ordination between different disciplines of treatment was required; and
- Warning signs or ‘red flags’ had not been acted on in this particular case and inadequate care may have contributed to the Deceased’s decision to take her own life.
This new and specialist evidence had implications on:
- The consideration of the nature and standard of care the Deceased received and whether any act or omission in her care contributed to her death;
- Whether a PFD report may be appropriate;
- The extent of the public’s interest in more being known about the dangers of Diabulimia;
- The weight to be afforded to the concerns and wishes of the Deceased’s family;
- The Coroner’s failure to comply with Rule 23 of the Coroner’s (Inquest) Rules 2013 by admitting only written evidence of a psychological therapist involved in the Deceased’s care (rather than oral evidence to explore matters further); and
- The possibility that a different and more detailed narrative conclusion would be recorded at the end of a fresh inquest.
Prevention of future deaths
The expert’s findings are key, not only to the re-consideration of the care the Deceased received, but also to the question of PFD and the wider impact of such a report.
A coroner is under a duty to consider the appropriateness of making a PFD report as part of the inquest process, pursuant to Regulation 28 of The Coroners (Investigations) Regulations 2013. Such a report is to be made where a coroner has considered all of the evidence and is of the view that further avoidable deaths could happen if preventative action is not taken. Whilst interested parties and their legal representatives can make submissions on whether or not such a report should be considered, it is ultimately up to the coroner presiding over the inquest to make this important decision.
Once made, the report is sent to the person or authority with the power to make the changes recommended by the coroner. The person or authority is placed under a duty to provide a response to the coroner within 56 days of the report. This response must detail any action taken (or proposed) and a timetable for implementing the same or an explanation as to why no action has been proposed. Both the report and any responses are available in the public domain.
Comment
PFD reports are arguably an essential aspect of the inquest process, given that the reports place on individuals and organisations a positive duty to make and provide tangible proof of the changes made to ensure that deaths do not occur in similar circumstances in the future.
In the majority of inquest cases where the evidence points to someone’s death being avoidable, their loved ones take great comfort and reassurance from knowing that changes will be made to prevent something similar from happening to someone else in the future.
In this case, it was only following expert opinion that the outstanding issues requiring further investigation, in this case, have become apparent. The outcome of the inquest may well have been different had the Defendant’s Coroner obtained independent expert evidence from a specialist as part of the initial investigation.
The Claimant’s application highlighted a number of potential systemic issues relating to this condition, particularly the need for a better understanding of the nature and incidence of Diabulimia among clinicians. This could lead to more screening and assessment of patients and subsequently, reduce the number of deaths that occur as a result of this condition. It is hoped that the conclusions reached following a fresh inquest will have a real and long-lasting impact on the future assessment and treatment of individuals with Diabulimia.
How can we help
Shrdha Kapoor is a Trainee Solicitor in our expert Medical Negligence team.
If you have any questions about the topics in this article or the inquest process more generally, please contact Shrdha or another member of the team in Derby, Leicester, or Nottingham on 0800 024 1976 or via our online form.
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