R v HER MAJESTY’S CORONER FOR THE BOROUGH OF SUNDERLAND

ex parte SHAW

Queen’s Bench Division

Crown Office List

Bingham LJ, Hodgson J

22 April 1991

G Kavanagh (instructed by James Shaw & Co., Sunderland) for the applicant;

J Freedman for South Tyneside Health Authority

BINGHAM LJ:  This is an application under section 13 of the Coroners Act 1988 that the inquisition on an inquest into the death of Paul Thomas Farrer be quashed.  The application is made under section 13(1)(b), the relevant language being this:

"This section applies where, on an application by or under the authority of the Attorney-General, the High Court is satisfied as respect a coroner (‘the coroner concerned’) either -- … or

(b)  where an inquest has been held by him, that (whether by reason of fraud, rejection of evidence, irregularity of proceedings, insufficiency or inquiry, the discovery of new facts or evidence or otherwise) it is necessary or desirable in the interests of justice that another inquest should be held.”

I emphasize at the outset that the basis of this application is discovery of new facts or evidence and not any question of rejection of evidence, irregularity of proceedings or insufficiency of inquiry.

The facts put very briefly are these.  Paul Thomas Farrer was a boy aged ten.  On 23^rd April 1988 he was taken out for the day by his father.  In the course of the day, when playing on a children’s slide, he fell off and broke his arm.  He was taken to South Shields Ingham Infirmary where he was given a general anaesthetic and an operation was performed for the purposes of reducing the fracture.  In the course of the operation he suffered a cardiac arrest.  He was transferred to the Sunderland District General Hospital where he died on 29^th April 1988.

The coroner for the borough of Sunderland, the present applicant, ordered that an inquisition be held, and duly held an inquest which was opened on 4^th May and concluded on 25^th October 1988 without a jury.  In the course of the inquest the coroner heard evidence from a number of witnesses, including evidence from the anaesthetist and the surgeon involved in the operation.  He recorded a death by misadventure.

Later, the South Tyneside Health Authority, at the instigation of the Northern Regional Health Authority, very properly held an internal inquiry into this death.  The Inquiry made a report which was in due course forwarded to the coroner.  It is inappropriate to go into the details of that report save to say that the Inquiry heard and reported evidence which was in some important respects markedly different from that which had been adduced before the coroner.  In particular, there was evidence to suggest that the anaesthetic given to this child was not given in the manner in which it should have been and material to suggest that the anaesthetist may have been seriously at fault.  I emphasize the words “may have been” since the facts have not been the subject of judicial investigation.

Upon hearing these new facts the coroner informed the representatives of the deceased, who pressed that the inquest be re-opened and that a fresh inquest be held.  Eventually the coroner concluded that it was appropriate that he should seek the Attorney General’s leave under section 13 for the holding of a fresh inquest and the quashing of the inquisition that he had held.  The Attorney General duly gave his leave.  This application is accordingly made, the only party represented being the health authority which not only does not oppose the application but actively supports it.

Having had the opportunity of considering the papers, and without describing the facts in more detail for fear of prejudicing the inquiry that we conclude should be held, I am for my part in no doubt at all that it is desirable in the interests of justice that another inquest should be held into this most unfortunate mishap.  It is plain from the affidavit, helpfully sworn by the coroner, that the facts may indicate a different verdict from the verdict of death by misadventure previously recorded.  It is desirable that the family of this young boy should have the opportunity of hearing the matter fully explored in evidence.

I would accordingly make an order quashing the inquisition which has already been held and ordering that a further inquest be held by Her Majesty’s Coroner for the Borough of Sunderland, who conducted the previous inquisition.  It is in every way appropriate that he should conduct the further inquisition since he has not in any way disqualified himself and since indeed he is already familiar with the background to this matter.

HODGSON J.  I entirely agree.

Solicitors: James A Shaw & Co, Sunderland; Solicitor, South Tyneside Health Authority.

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