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	England and Wales High Court (Administrative Court) Decisions
You are here: BAILII >> Databases >> England and Wales High Court (Administrative Court) Decisions >> Combe v HM Coroner for Blackburn, Hyndburn & Ribble Valley [2005] EWHC 2843 (Admin) (18 November 2005) URL: http://www.bailii.org/ew/cases/EWHC/Admin/2005/2843.html Cite as: [2005] EWHC 2843 (Admin)

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IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
DIVISIONAL COURT

		Royal Courts of Justice Strand London WC2
		18th November 2005

1. LORD JUSTICE GAGE: I will ask Mr Justice Openshaw to give the first judgment.
2. MR JUSTICE OPENSHAW: With the leave of the Solicitor-General, Pauline Combe, the former partner of William Tatters, applies to this court under section 13(1)(b) of the Coroners Act 1988 to quash the inquisition in respect of Williams Tatters taken before Her Majesty's Coroner for Blackburn, Hyndburn and Ribble Valley at an inquest held on 13th November 2003 and closed on 10th February 2004, and to order that a new inquest is held. This application, very properly, is not opposed by the coroner.
3. The facts in bare outline are these. Mr Tatters was born on 14th October 1951. He worked as a miner. He had a long exposure to a variety of harmful dusts and fumes. In consequence he contracted chronic obstructive pulmonary disease.
4. On 1st November 2003 Mr Tatters was admitted to Blackburn Royal Infirmary with shortness of breath. His condition worsened. He was transferred to Queens Park Hospital on 3rd November, where he died on 7th November. The post-mortem gave the cause of death as being bronchopneumonia leading to chronic obstructive airways disease and ischaemic heart disease. In due course, at the inquest a verdict of death by natural causes was recorded.
5. However, Pauline Combe knew that only 12 hours before his death Mr Tatters had fallen from his bed. She mentioned this in a witness statement by the Coroner's Officer at the time. She claimed that he had cut his head, and indeed had a swelling to his face. The nurses' notes fully document how Mr Tatters was found on the floor in advanced respiratory distress, having fallen from his bed. There is no mention, however, of the fall in the clinical notes. No one has so far sought to examine the reason for this omission.
6. Since the particulars for the sudden death inquiry form were taken from the clinical notes, the fact that the fall did not apparently come at the time to the notice of the coroner, but whether the pathologist knew of the fall and was alerted to the possibility of head injuries is unclear. There was as a result at the time no proper and detailed investigation of these matters, and of course no investigation of these matters at the inquest. This, as the coroner now accepts, was regrettable.
7. When vulnerable patients die in hospital after a fall, there needs to be a full examination of the circumstances. There would appear to be a number of outstanding questions, among them: did Mr Tatters fall from his bed? If so, why did he fall? Why is there no mention of the fall in the clinical notes? Could, and indeed should, precautions have been taken by way of a bed rail or otherwise to lessen the risks of a fall? Might such precautions have prevented the fall in this case? Was the pathologist alerted to the fact of the fall? How thorough was the post-mortem? Were there any injuries referable to the fall; and, if so, did those injuries cause or contribute to his death?
8. Having regard to the limitations on the functions of the coroner, it may not be appropriate for him formally to make findings on each of these matters, but there should now be a thorough and searching investigation of all the circumstances surrounding the death of Mr Tatters, so that the coroner can discover and consider all the relevant material. It will then be for him to hear and determine these issues as the law requires.
9. Accordingly, in my judgment, the original inquisition and verdict should be quashed and a new inquest should be ordered.
10. LORD JUSTICE GAGE: I agree.
11. All you seek, I say all, is orders quashing the verdict and directing that a new inquest be held.
12. MR THOMAS: Yes, I am publicly funded.
13. LORD JUSTICE GAGE: Yes.
14. MR THOMAS: So I would ask for detailed assessment of my publicly funded certificate, if that is the correct wording.
15. LORD JUSTICE GAGE: You may have it. Thank you very much for all the hard work that you put into it. It had made this a lot easier Mr Thomas for us to follow it through.
16. MR THOMAS: Thank you.
17. MR JUSTICE OPENSHAW: Thank you.