R (Olabode) v HM Area Coroner for Manchester City & Manchester University NHSF Trust (2026) EWHC 810, 2 April 2026, judgment here.
Coroners and inquest practitioners seeing this 31 page judgment land on a Maundy Thursday need not worry that they might now have a lot of reading to interrupt their Easter break. Despite the lengthy, detailed and erudite judgment of Mrs Justice Hill this case does not develop coronial law one iota – it is a case uniquely confined to its facts.
But gosh! what an incredibly complex set of facts these were. Indeed Hill J is rather playing down the intricate detail she had to grapple with when she opens her judgment saying that “this claim has involved the consideration of incredibly detailed expert evidence”. There were eight experts from seven specialist medical disciplines who provided their views to the Coroner on cause of death and causation during the inquest under challenge. Inevitably they did not all agree with each other: indeed they agreed and disagreed in different ways on different things. The medical evidence was so convoluted that those present in the Admin Court in Manchester last week report that a far more apt reference was made at the hearing to “needing a towel on the head” before one might even begin to understand it.
As anyone who was not born this century ought to know, a towel is of course about the most massively useful thing an interstellar hitchhiker can have.[1] But happily you won’t need your own towel here, as Hill J has done all the hard work for you. Just jump to paragraph 113 to find the single learning point for coroners and inquest practitioners that comes out of this case, which is:
When inquest evidence is this complicated, and even if Art 2 is not engaged, it’s a jolly good idea for counsel to help out the coroner by proposing a list of key issues that the coroner should consider and cover off when coming to their findings of fact.
And then perhaps also join your blogger in celebrating the forensic analytical skills of both the Area Coroner for Manchester City and Hill J[2] next towel day, on 25 May (assuming there is no appeal, in which case three more towels will probably be needed).
The background
The Claimant’s 12-year-old daughter, Victoria, had been under the in-patient care of the NHS Trust when she suffered a fatal stroke which was a complication of her sickle cell disease. After Victoria’s death a review conducted by the NHS Trust identified a series of problems with the care provided during her admission. In very brief summary these related to a failure to conduct any imaging over a weekend, the absence of a multidisciplinary review, the failure to document neurological observations and the timing of an exchange blood transfusion.
The Inquest Evidence
A key focus of the inquest which inevitably followed was the causative relevance of the absence of imaging; in particular, what would have been shown had the imaging been undertaken as it should and what action might then have followed, with what outcome.
The Area Coroner heard evidence from a series of Trust clinicians and independent experts, each of whom did their best to assist from their particular super-specialist vantage point. But, as can often be the case when a series of extremely complex medical events are being reviewed, these experts at times deferred to the expert from another speciality as to the clinical consequence of their own opinion and on several points their views were incompatible. The lines of logic can so easily become tangled when different views and perspectives interdigitate in this way. Even hot-tubbing some experts did not lead to a consistent or unified position.
The picture was made more complex when the NHS Trust, having initially considered that the identified shortcomings in care had been causative of Victoria’s death, changed its view as to the causative effect of the failings after considering some additional expert evidence. Having heard two days of oral evidence the Area Coroner realised further expert reports were going to be needed to help him try and untangle a complex web of haematological, radiological, neurological, neuroradiological and physiological opinion.
A relatively long adjournment followed so that new reports and joint reports might be prepared, some of which were in response to an earlier report by another expert. After resuming for two more days of oral hearings the Area Coroner had by the end heard or considered written reports from eight different doctors. These were: two Consultant Paediatric Neurologists; a Professor of Paediatric Neurology; a Consultant Neuroradiologist; a Consultant Paediatric Neuroradiologist a Professor of Paediatric Neuroradiology; a Professor of Paediatric Neuro-oncology; and a Consultant Haematologist. By agreement the Coroner also admitted a significant amount of factual evidence under Rule 23 of the Coroners (Inquests) Rules 2013. The various reports, transcripts and notes of evidence ran to around 850 pages.
In the judge’s view the Area Coroner had “conducted the inquest in a very thorough manner.” His decision to adjourn the inquest to obtain further expert evidence and the comprehensive way in which he questioned the witnesses made it “clear he was seeking to test the evidence with which he was being provided, in order to discharge his duty of inquiry.” [3] Indeed as Hill J remarked: [4]
“Overall [the Area Coroner] received a significant body of highly complex, multi-faceted expert evidence. The experts gave evidence from a range of disciplines. In various respects, they quite rightly deferred to the views of others, given their respective areas of expertise. There was no single expert able to give a definitive view of whether there had been any failings in Victoria’s care and whether any such failings contributed to Victoria’s death. There were conflicts in the expert evidence on some of the key issues.
Given that background, it was not possible nor was it evidentially appropriate for the Defendant to consider any aspect of that evidence in the abstract or as a separate and discrete matter divorced from the opinion of others. Rather, it was necessary for him to look at the expert evidence “in the round”. He also had to weigh up the conflicts in the evidence between the experts and resolve them where necessary to determine the key issues.
In my judgement this was a challenging exercise. This was particularly so, given the volume of written reports, oral evidence, and the gap in time between the first and second phases of the inquest; the nuanced nature of much of the evidence; and the fact that the experts were required to express opinions and conclusions by reference to a serious of hypotheses.”
At the end of the evidence, counsel appearing for Victoria’s family and for the Trust each made brief submissions as to the permissible conclusions available. In effect, they agreed that the Coroner could return a “short form” conclusion of natural causes, but that if he identified any failings in Victoria’s care which had contributed to her death a narrative conclusion would be preferable. The Coroner then suggested to both counsel that he might be assisted by submissions as to the “specific issues [on] which I need to make findings” however neither counsel took up his offer to make any such submissions.
The Coroner then adjourned to consider his conclusion. He made a series of findings of facts, including that had imaging been done as it should have it would not have demonstrated a need for the different management that might have avoided the stroke. He concluded on the Record of Inquest that: [5]
“…On 5th July 2019, Victoria developed sudden onset of vomiting and severe headaches. The headache persisted for three days, and on the morning of 8th July 2019 she suffered two seizures. Radiology confirmed ischaemic brain injury, and she was subsequently transferred to PICU. On 9th July she underwent an exchange transfusion, and a CT scan demonstrated widespread cerebral infarction. She met the criteria for brain stem death following testing …”
In his findings of fact the Coroner explained that he did not accept that imaging on 6th July would have led to a significant escalation in Victoria’s care. He said: “I have found failures in her care, none of these failures more than minimally contributed to her death on the balance of probabilities. As a matter of law, the factual circumstances of Victoria’s death fits squarely within the legal definition of ‘Natural Causes’, and therefore I will return this as a short-form conclusion”.
The Judicial Review claim
The Claimant who did not accept the finding on causation, brought a claim seeking a fresh inquest on three grounds. The first related to the Coroner’s approach to the alleged failings in care by the hospital. The second related to his approach to causation. A third (shifting) ground ultimately became an argument about the materiality of any errors identified under the first two grounds.
Like the inquest, the JR claim also then had a lengthy procedural history. The Claimant was initially refused permission to bring a Judicial Review claim on the papers by HHJ Pearce. At the oral renewal hearing permission was again refused by HHJ Sefton KC (see [2024] EWHC 3471 (Admin)). The Claimant’s appeal against that refusal was however allowed by Holgate LJ and so it was that the substantive claim came before Mrs Justice Hill.
The judge’s decision
This being a Judicial Review claim it was not an appeal. The fact that another coroner or even a High Court judge might have reached a different conclusion on much the same material would not entitle the Claimant to relief: rather, the question was whether this coroner had reached a conclusion that was open to him as a reasonable coroner. Hill J also reminded herself that in assessing the adequacy of the reasons given in his findings of fact, the Coroner’s decision should be looked at “in the round”; and that the court should not be “invited…to apply a very fine tooth comb to the evidence given at the inquest and to the statement of reasons and to go through a minute analysis of each and every point.
Nevertheless the judge was invited to conduct a very close analysis of the evidence herself so that she might then come to her decision about the reasonableness of the Coroner’s conclusion. Hill J observes that[6] “I confess I found the task asked of me …- simply to review all the evidence myself – an unusual one, in the context of a judicial review. Such claims are, by definition, focussed on identifying public law errors in an underlying decision rather than re-assessing the facts. I was initially concerned that I was being asked to do the “very fine tooth comb” exercise what had been discouraged [by earlier authorities]”
However, as the public law error at the heart of Ground 1 was an alleged failure to deal with a key issue, it was clear to the judge that she too needed to put a metaphorical towel over her own head and review the 850 pages of complex medical opinions that had been put before her
It is not now necessary to ruin anyone’s Easter break by reciting the detail of what the judge found having conducted her analysis of the evidence, it is enough to quote para 114 of her judgment:
“I consider that the Defendant is to be commended for producing such a concise but detailed judgement which on any view engaged with the key issue of whether scanning should have been ordered in Victoria’s case and whether the failure to do so contributed to her death. The Defendant logically moved through the analysis, finding the failure in relation to the scanning, then addressing what the consequences of that were, before turning to the hypothetical scenario of whether the failure to conduct an exchange transfusion on 6 July 2026 made a more than minimal contribution to Victoria’s death.”
Hill J noted how “for completeness” the Coroner had also dealt with issue of “what steps would likely have been taken had [he] found that scans on 6th July 2019 would have shown subarachnoid blood’. He did so “in order to make further findings relating to whether Victoria’s death was avoidable” but “with the clear caveat that I do not accept that scans on 6th July 2019 would have led to a significant escalation in Victoria’s care”.
In a nutshell then, the Judge did not accept the Claimant’s analysis of the complex evidence and so did not agree that, in this very difficult evidential exercise, the Coroner had erred by leaving relevant matters out of account. She held that the Coroner had not, as the Claimant averred, unreasonably discounted one doctor’s evidence in respect of causation on an incorrect basis. As Ground 1 had been dismissed, then Ground 2 had become largely academic. By the time of the hearing the third ground based on a legal misdirection on causation was no being longer pursued. The claim was therefore dismissed.
Commentary
In the midst of this complex web evidence one should not forget that a 12 year old child had died. Her parents who initially understood that the NHS Trust accepted some clinical shortcomings had contributed to her death were entitled to feel confused and aggrieved when the evidential picture changed. It is perhaps unsurprising that they wished to pursue this claim when the Coroner having sought and analysed some fresh evidence was not persuaded of the causative link. The evidence here was as complicated as one might ever come across in any inquest. The cause of Victoria’s death was not in dispute, but whether her death could or should have been prevented was a contentious matter that was made even more difficult by the nuanced and incredibly complex nature of the expert evidence.
Having conducted her own detailed analysis of the medical issues the judge remarked (at §113) that it was “regrettable that in approaching the task of reaching his conclusion the Defendant was not doing so with the benefit of an agreed list of the issues he needed to address”. This is a perceptive observation. The Coroner had clearly invited counsel’s assistance with drawing up a list of issues at the inquest. Despite that invitation the issues that the Claimant now complained had been overlooked had not been spelled out at the time as the important ones for the Coroner to address head on by the (different) counsel who had appeared for the family at the inquest. You might ask yourself, as this blogger did, how it came to be that an open invitation from the coroner for assistance with a list of issues to consider was met with essentially: ‘I don’t see a need to do that.’ Although the judge also noted that when the requested assistance was not given the Coroner had not then formally directed it. As Hill J pointed out “such a list could, with care, have been prepared without transgressing the Coroners (Inquests) Rules 2013, Rule 27, which precludes addresses to the Coroner on the facts.” If a list had been drawn up it would have assisted the Coroner in taking a more structured approach in his ruling on the causation issues that the family now complained about. Although the Coroner had ultimately made lawful findings it might have ensured there was no room for any misunderstanding on the Claimant’s part about what he had and had not found and why.
Bridget Dolan KC of Serjeants’ Inn represented the Coroner in this claim.
Footnotes
[1] If this reference means nothing to you then you should decline chocolate and ask the Easter Bunny to buy you all four books in Douglas Adams’ wonderful Hitchhikers ‘trilogy’ instead.
[2] Yes, we know this blog keeps fan-girling her. But it is so good to have such an exceptionally bright judge who has an informed understanding of what inquests are all about deciding these tricky case.
[3] §109
[4] §§110-112
[5] This is an edited summary
[6] §115