Applying for a fresh inquest is not straightforward. First, the bereaved have to get permission from the Attorney General. Only once that authority has been granted will they be allowed to apply to the High Court to reopen the inquest (section 13 of the Coroners Act 1988). Often cases are reopened because new evidence has come to light or there has been insufficiency of inquiry, for example where a person is found guilty of the murder of the deceased or new scientific data is provided. Further, it has to be necessary or desirable in the interests of justice that an investigation be (re)opened.
This case does not provide any new legal principles, but it is a strong statement about the importance of testing the evidence before granting the fiat: inquests should not be reopened just to allay the concerns of family members.
Facts and judgment
This case has a tragic backstory brought about by a complete breakdown of relations between a mother and her stepdaughter.
Ray Farrell died on 24 October 2016 aged 53 as a result of malignant mesothelioma, which he developed following asbestos exposure working as a mate’s fitter. He had settled a civil claim with his former employer prior to his death. The documentary-only inquest recorded the cause of death as mesothelioma. There was no post-mortem or toxicology, as the histology of mesothelioma was considered sufficient.
Concerns were first raised by his daughter, Kelly, who had not been informed of her father’s illness and therefore was shocked to discover his illness and death. Her suspicions were raised by two matters: two carrier bags full of medicines awaiting disposal following his death and a response from the Senior Coroner to her email that there were no toxicology or blood samples because Mr Farrell’s wife, and her stepmother, was very anxious to avoid a post-mortem. In fact, it was Mr Farrell who did not want a post-mortem.
Her concerns were then taken up by Ray’s mother, Mrs Farrell. She applied for a fresh inquest on the basis that Mr Farrell’s wife, Amanda Burden, hastened his death by deliberately giving him inappropriate medication. Ms Burden and Mr Farrell had been married in February 2016, although they had been in a relationship for eight years. She was, Mrs Farrell alleged, motivated by financial gain. Mrs Farrell applied with the fiat of the Attorney General under s.13 of the Coroners Act 1988 for the quashing of the original inquest due to a lack of appropriate investigation. The Senior Coroner supported the fiat, although doubted whether the outcome would be any different.
However, it was robustly dismissed by the Divisional Court, which included the Chief Coroner, on the basis that there was no basis of a fresh inquest reaching a different conclusion or finding any substance to Mrs Farrell’s suspicions.
Mrs Farrell, a retired nurse who represented herself, raised a number of issues, which were resolved by the Divisional Court:
- The wedding of her son and Ms Burden was hastily arranged in February 2016. A new will was signed on the same day, witnessed by his parents. She alleged that Ray was drugged and lacked capacity for either the marriage or the drawing up of the will. But the Divisional Court pointed to documentary evidence that the wedding was clearly planned, he had capacity to make that decision, his parents attended and no one had raised any concerns at the time or in the eight months leading to his death. As to Ray being drugged at the time of his wedding, this was undermined by the fact that the drug, Midazolam, was not prescribed until 10 days before his death.
- As to the absence of a post-mortem, Mr Farrell had specifically requested that no post-mortem took place, as evidenced by the GP’s medical records and correspondence with the Senior Coroner prior to his death.
- There was nothing suspicious in relation to the timing and nature of Mr Farrell’s death, or the amount of medication he had received. His GP had expected him to die and he was receiving palliative care. The court had a report from Professor Britton, a distinguished retired consultant physician who was a mesothelioma expert. Having reviewed the medical records, he concluded that the timing and nature of Mr Farrell’s death was usual for a patient suffering from mesothelioma, and there was nothing in the history or records that caused him concern or that would have hastened his death. Also, there was nothing surprising about the volume of medication given he was receiving end of life care.
- The alleged financial motivation by Ms Burden did not make sense – why would she seek to hasten his death by days, when there was no reason to think that his financial position would change within that time?
- There was no realistic prospect of a fresh inquest reaching a different conclusion because there would be no new findings of fact or any new empirical data.
Lord Justice Popplewell, giving the judgment of the court, concluded at :
“To permit a reinvestigation would cause unwarranted distress to Ms Burden by the continued public airing of the serious allegations being made by Mrs Farrell, and similarly to other healthcare professionals accused of impropriety or failings. It would cause cost and delay to the coroner’s service. It would divert the health professionals involved away from their public service by requiring preparation for and attendance at a hearing. The interests of justice do not require that Mrs Farrell be given a platform to air her unjustified suspicions.”
He also stated:
“This is not the kind of exceptional case in which there has been an insufficiency of investigation and a fresh inquest can be justified simply to allay concerns of members of the bereaved family irrespective of the possibility of a different outcome. Judging by the misguided passion with which Mrs Farrell advanced her suspicions before this court, and her maintenance of arguments flatly contradicted by the contemporaneous records, I fear that she would no more be satisfied by their rejection at a second inquest than she is with the fact they were not considered at the inquest which has taken place.”
This was not the first court case between Mrs Farrell and Ms Burden. Mrs Farrell also sued Ms Burden and her friend in their capacity as Mr Farrell’s co-executors, claiming she was owed money out of his estate because she had contributed to his house purchase. That case was also dismissed, on the basis she could not prove that the sum was a loan rather than a gift. The court, though, noted the catastrophic breakdown in relations between Mrs Farrell and Ms Burden.
In this case, the court’s judgment highlighted the exceptional nature of reopening an inquest, balancing the cost and delay to the coroner’s service, and the diversion of health professionals from their work against the need to review allegations. Given the evidence did not support Mrs Farrell’s position at all, that would have been sufficient on its own to dismiss the application. However, the court also stressed the importance of not giving Mrs Farrell a platform to make further unsubstantiated claims against Ms Burden or the healthcare staff. It is a salutary reminder to ensure there is a sound legal basis for reopening an investigation, rather than the bereaved simply attempting to usurp an outcome they do not like.
Peter Skelton QC of 1 Crown Office Row, represented Ms Burden in this case. He was not involving in writing this article. This piece also appeared on the UK Human Rights Blog.