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Successful Judicial Review Challenge Quashing The First Inquest Into The death of Vulnerable Man, Peter Seaby

Hodge Jones & Allen recently assisted a grieving family in their battle to obtain answers following the loss of their beloved brother, acting in a successful judicial review of the outcome of the first inquest into his death.

The First Inquest

Peter Seaby was 63 and vulnerable at the time of his tragic death on 22 May 2018. He had Down’s Syndrome and learning difficulties alongside a number of physical comorbidities, including reflux and dysphagia.

In December 2017, Norfolk County Council’s social services made a best interest decision which determined that Peter should be moved from his family home and placed into residential care. He was placed at the Oaks and Woodcroft care home in Norfolk, a specialist residential home for people with learning disabilities, run by Priory Adult Care.

Whilst living at Oaks and Woodcroft, Peter was subject to a strict eating/drinking and swallowing care plan formulated by the SALT (Dysphagia) Services of Norfolk Community NHS Health and Care NHS Trust. This stipulated the foods he could eat and how it should be prepared, as well as the level of supervision Peter required around meal times. The care plan set out the clear risk that failure to follow the plan could result in Peter suffering potentially life threatening aspiration or asphyxiation.

Over the following five months during which Peter lived in their care, there is evidence to show that staff repeatedly did not adhere to the care plan and that Peter experienced a choking incident on at least one occasion.

On 22 May 2018, Peter died of aspiration pneumonia. At post-mortem a whole slice of carrot, approximately 2cm in diameter, was found in his throat. The care plan had set out clearly that Peter should not have been fed hard foods of that size.

HM Area Coroner for Norfolk, Ms Yvonne Blake (sitting with a jury), held an inquest into Peter’s death which opened on 16 August 2021. The family were represented by Priya Singh of our Medical Negligence department and Simon Cridland of Serjeants’ Inn.

Despite strong argument from the family, the Coroner ruled that this was not an inquest where the state’s substantive and investigative obligations under Article 2 ECHR were engaged and also rejected the family’s submission that the rider of neglect should be left to the jury to consider.

The inquest concluded on 23 August 2021, which recorded the short form conclusion of ‘natural causes’.

The Judicial Review Challenge

Wholly disappointed by the conduct of the inquest and its outcome, the family instructed Priya Singh, assisted by Megan Finnis Trainee Solicitor, and Simon Cridland to represent them in a Judicial Review challenge of the same. The application sought the following remedy:

  1. An order that the conclusion of the jury, and the record of inquest be quashed; and
  2. The matter be remitted back to the Coroner’s Court in order for a fresh inquest be held.

The grounds of challenge were that, in making the two determinations regarding the applicability of Article 2 and the rider of neglect, the Defendant had erred in law and/or acted irrationally in that she reached a conclusion that was not reasonably open to her on the evidence and had she properly directed herself to the law.

Upon receipt of the family’s letter before claim and Statement of Facts and Grounds, which set out the basis of the challenge, neither the Coroner nor any of the Interested Parties to the original inquest contested the application.

On 17 January 2022, the Court handed down an Order in the terms sought, quashing the conclusion and record of inquest of the first inquest and ordering that a fresh inquest be held by a different Coroner.

What happens next?

Often, there are times when the Coronial system can be extremely difficult for bereaved families to traverse. Although the process is governed by Statute and overseen by the Chief Coroner, each Coroner holds wide powers of discretion and it can be difficult for families and their Solicitors to predict what shape the proceedings will take and what the outcome will be.

Despite the prolonged and difficult legal journey they have had to take, the Seaby family have remained determined to find answers as to the circumstances of Peter’s death and are heartened that, following the successful Judicial Review, they will have the opportunity to hear all of the relevant evidence in a fresh inquest. Their hope is that lessons can be learned by all those involved with Peter’s care, so that other potentially avoidable deaths will be prevented.

The family awaits the listing of the second inquest, in which they will again be represented by Priya Singh and Simon Cridland.

If you or your loved one have suffered injuries or sadly passed away due to care home negligence we may be able to help. For a free initial consultation with one of our medical negligence experts please call 0330 822 3451 or request a call back online.