RE SHEPPARD DECEASED

Queen’s Bench Division

Crown Office List

Beldam LJ, Laws J

22 April 1991

P Marshall (instructed by Hood, Vores & Allwood, Dereham, Norfolk) for the applicant;

The respondent did not appear and was not represented.

BELDAM LJ: (reading the judgment of the court): Brent Sheppard, who was 42 years of age, died at Hurstwood Park Hospital in Haywards Heath shortly after 11pm on 25^th March 1991.  He had been admitted there, following a fall, either on 24^th or 25^th March.  He was apparently in poor health and he had suffered from alcoholism, hypertension and jaundice, and on one occasion, apparently, had had an attack of epilepsy.  At the time of his death he was living with his mother, Mrs Enid Sheppard at 37 Benfield Road, Hove.  His mother, who was naturally upset by his death, told the coroner’s officer, Mr Matthews, that the deceased had fallen just before 6.30am in the kitchen and in falling had struck his head on a kitchen fitment.

At Hurstwood Park Hospital a brain scan was performed.  That showed that the deceased had a subdural haematoma.  The doctors operated upon the haematoma, but unfortunately they were unable to save his life.  As stated, he died shortly after 11pm that day.

Dr Elspeth Morrison, a consultant pathologist, carried out an autopsy.  In her opinion the cause of death was a brain stem haemorrhage due to subdural haemorrhage, and she commented that death was due to the fall which caused the subdural haemorrhage.  It would appear that the brain stem haemorrhage was secondary to this.

The deputy coroner, Mr Bernard Crymble, decide to hold an inquest.  It was held on 17^th April.  The evidence before the coroner consisted of a medical report from the deceased’s general practitioner, giving the history I have already outlined, a statement by the coroner’s office as to what he had been told and the post-mortem report.  In accordance with rule 12 and form 18 in the third Schedule of The Coroners Rules 1953 the injury or disease causing death could only be that set out in the post-mortem report, namely brain stem haemorrhage due to subdural haemorrhage.  The conclusion of the coroner as to the death, on the evidence, could only be accident or misadventure, again in accordance with that Schedule.

The coroner, according to an affidavit which he has filed, is a consultant neurosurgeon with over 40 years experience.  He apparently decided on the basis of that experience that the cause of the subdural haematoma could have been spontaneous bleeding It may well be that he was led to this conclusion by the wording of his coroner’s officer’s report, which referred to the deceased having collapsed before falling and striking his head.  He appears to have overlooked the clear evidence of a fall, of the striking of the head and of the opinion of the pathologist who conducted the post-mortem.  Consequently he gave it as his conclusion in paragraph 4 of the inquisition:  “Conclusion of the coroner as to the death: Verdict: Natural Causes”.  The immediate cause of death was quite clearly the brain stem haemorrhage following subdural haematoma.  Whether this was due to hypertensive bleeding brought on by jaundice and alcoholism or due to a fall, causing the deceased to strike his head, would in fact have been of no significance but for the fact that very shortly after the inquisition the deputy coroner received word from an interested relative that there was in existence an insurance policy on which a sum would become payable on a certain contingencies, one of which was death by accident.

Accordingly, the deputy coroner caused further inquiries to be made.  As a result the deceased’s mother gave Mr Matthews, the officer, an expanded account of the circumstances leading up to the deceased’s admission to hospital.  In this account she said that the fall had occurred on the previous evening and that the deceased had attributed his fall to slipping in the kitchen.  According to the deputy coroner, had this information been given to him at the time of the inquest he would have accepted that death was the result of accidental injury.

Consequently, he sought the fiat of the Attorney General to apply to the court under section 13 of the Coroners Act 1988 for an order that another inquest he held.  The Attorney General gave his flat on 25^th July 1991, but there were certain difficulties which stood in the way of those who were acting on the coroner’s behalf, combining with the application under section 13 an application for judicial review in accordance with the very helpful guidance which Woolf LJ gave in the course of his judgment in the case of Re Rapier (deceased) [1988] QB 26, [1986] 3 WLR 830.  Woolf LJ there pointed out that it was not necessary for two separate applications to be made.  They can be and are in practice often joined together.  As he said, the powers of the court on judicial review are wider than those granted under section 13 of the Coroners Act and are more flexible.  On judicial review the court can, for example, delete part of an inquisition and can give directions to the coroner to amend the finding in accordance with the evidence, as was done in the case of R v Inner West London Coroner ex parte De Luca [1988] 3 All ER 414, [1988] 3 WLR 286.  Such a course would avoid the necessity and expense of any further inquest and the difficulty which is manifest from the terms of section 13, that for an application under that section to succeed it must be shown to be necessary or desirable in the interests of justice that another inquest should be held.

In considering that question regard must also be had to rule 33 of the Coroners Rules, that no verdict can be framed in such a way as to appear to determine any question of civil liability between other parties.  The opinion of the coroner, as to the cause of death, is in my opinion irrelevant as between any parties to a claim under a policy of insurance.  Although the opinion he expressed was not in accordance with the evidence before him, the additional facts subsequently stated by the deceased’s mother hardly make it necessary or desirable in the interests of justice that another inquest should be held.  All that in fact is necessary is for the coroner to record the cause of death in accordance with the post-mortem report which was before him at the time of the original inquest, in the terms recommended in the notes to form 18 and Schedule 3 of the Coroners Rules, that Brent Sheppard died as a result of an accident/misadventure.

In those circumstances Mr Marshall recognized the difficulties which this application faced and the further difficulty that it would not, on the face of it, be open to the coroner to apply to the court for leave to present a claim for judicial review of his own decision.  Such an application could, it seems to the court, conveniently be made by an interested relative.  There are clearly interested relatives in this case.

Consequently what we propose to do is to adjourn the hearing of this application in order to give Mr Marshall, who appears here today on behalf of the coroner, time to seek instructions so that, if necessary, an application can be presented for leave.  Although it is not for this court to say that time should be extended, it has been said that it would only be in the most exceptional cases that where the Attorney General has given his fiat under section 13 the court would refuse to give leave for judicial review.

We propose to adjourn this matter for Mr Marshall to obtain instructions and to present his alternative claim for judicial review when he has obtained leave.

Solicitor:  Mr H Cartright, County Secretary and Solicitor, East Sussex County Council.

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