It emerged recently that there were “serious failings” in the care of a mother who died hours after she gave birth. Shortly after Gabriela Pintilie gave birth to a baby girl, Mrs Pintilie bled to death, despite the staff having received the blood products needed to save her life.
During the course of the inquest, coroner Caroline Beasley-Murray said there had been delays, confusion and a lack of leadership in the care of Mrs Pintilie.
As with the tragic death of Mrs Pintilie, an inquest had taken place to determine the cause of death. Inquests may take place following a death in certain circumstances, such as where a death was sudden and the cause is unknown, or where someone has died an unnatural or violent death, or where someone has died in a place or circumstance where there is legal requirement to hold an inquest, for example in prison custody or whilst sectioned under the Mental Health Act: frequently such inquests are referred to as ‘Article 2’ inquests.
Article 2 of the European Convention of Human Rights is the right to life, meaning the state has a general duty to protect life. An Article 2 Inquest is held if your relative dies on a mental health ward, whilst being detained in prison, an immigration centre or in police custody. The role of the Coroner is to investigate who has died, when, where and how (the cause of death).
What can I do if my relative has died and an Article 2 Inquest will be taking place?
To assist you during an inquest, you may need a solicitor who specialises in Human Rights and Mental Health law or Clinical Negligence. Your solicitor can assist in gathering further information for you and taking your full instructions. Your solicitor will also make contact with the Coroner at the outset to notify them that he/she is representing you at the inquest and they can also request a list of witnesses and ascertain the position with respect to expert evidence.
Conclusions that may be reached are as follows:
- Natural causes
- Self neglect
- Unlawful killing
- Lawful killing
- Accident or misadventure
- Road traffic Collision
A narrative conclusion involves a longer explanation of what the coroner or jury feel are important mistakes that have been made, especially in an Article 2 inquest. In some cases, “contributed by neglect” can be added to the conclusion. The touchstone of neglect as a Coronial conclusion remains the judgment of Sir Thomas Bingham MR in the Court of Appeal in Jamieson  QB 1:
“Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide or procure basic medical attention or shelter or warmth for someone in a dependent position (because of youth, age, illness or incarceration) who cannot provide it for himself. Failure to provide medical attention for a dependent person whose physical condition is such as to show that he obviously needs it may amount to neglect. So it may be if it is the dependent person’s mental condition which obviously calls for medical attention (as it would, for example, if a mental nurse observed that a patient had a propensity to swallow razor blades and failed to report this propensity to a doctor, in a case where the patient had no intention to cause himself injury but did thereafter swallow razor blades with fatal results). In both cases the crucial consideration will be what the dependent person’s condition, whether physical or mental, appeared to be.”
Legal help can cover all of the preparatory work associated with the inquest. Legal Aid can be provided to an individual in relation to an inquest into the death of a family member but excluding advocacy.
Your solicitor can advise you as to funding options available and will facilitate the process.
Article 2 inquests can be especially difficult and heart wrenching for families. To assist in the process, some coroner’s courts have waiting rooms so that you have somewhere to gather in private. However, some courts don’t have this therefore please speak to your solicitor or coroner’s court about this prior to the inquest.
Please bear in mind that press may go to the inquest and report on what is going on. Please speak to you solicitor about this so that you do not feel more distressed or very unprepared on the day.
The Coroner’s Court Support Service (CCSS) are a registered charity who can also provide support to you and your family during the inquest. The charity Inquest can also provide expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians.
During the course of the Inquest, you and your family will hear evidence from both sides and the final conclusion from the coroner or jury. It is important to remember that the conclusions that you make for yourself and what you believe are the most significant. Hopefully an inquest will provide some closure for you and your loved ones and help as part of your on-going healing process.