“Flagrant disregard for the inquest and its processes” – fines, prosecution and double jeopardy

R v Lawrence [2019] Wimbledon Magistrates Court

The unprecedented tale of “Dr.” Duncan Lawrence and his withholding of information from a coroner about his involvement in the death of the teenager Sophie Bennett has already gripped the headlines. This highly unusual criminal prosecution of a healthcare staff member who failed to give evidence at an inquest into the death of one of his patients is thought to be the first of its kind under the Coroners and Justice Act 2009[1]. The saga has now taken a further extraordinary turn.

Despite having pleaded “100% guilty” on 16 August 2019, on subsequently attending court for sentencing Lawrence sought and was given an adjournment so that he may consider resiling from his earlier guilty plea.

The question that arises is whether, having already been fined £650 in May 2019 by the Assistant Coroner for his non-attendance at the inquest (pursuant to Schedule 6 part 6 CJA 2009), Lawrence is being put in double jeopardy by the additional criminal prosecution of him under Schedule 6 part 7 of the Act.

The background

Sophie Bennett was 19 and suffered with mental health difficulties. She had moved to Lancaster Lodge, a residential home run by the Richmond Psychosocial Foundation International (‘RPFI’), where she was progressing well until Duncan Lawrence was appointed as Clinical Lead.

Lawrence made major changes the unit’s regime. The therapy program and daily routine were changed. He was said to have instigated a ‘boot-camp’ style regime, abandoning regular therapies in a management approach likened to “a dictatorship with 19th-century governance”[2]. It is reported that Lawrence planned to end all psychotherapy at the unit and replace it with yoga sessions[3].

At the inquest it was discovered that staff had wrongly understood Lawrence to be a medical doctor. Despite being employed as clinical lead it now appears that he had a doctorate in ‘public management and administration’ from an unaccredited institution in Denmark[4].

The manager left, and so did many of the staff. They were replaced by staff who were unqualified, untrained, and inexperienced.  Anonymous complaints made to the CQC led to a week-long unannounced inspection in March 2016: the CQC inspector said that, in all his many years of experience, he had never seen anything like what he found. Indeed the CQC has since informed the RPFI that it will be prosecuted under the Health and Social Care Act 2008 over an alleged failure to provide safe care and treatment, resulting in Sophie being exposed to the significant risk of avoidable harm, and the Charity Commission has also opened a statutory inquiry into the organisation[5].

Lawrence left Lancaster Lodge the day after the CQC arrived. An embargo was placed on Lancaster Lodge, admissions ceased and several of the residents were moved elsewhere.

The Local Authority took the view that it was essential that Sophie should also move to another placement. Sadly this action came too late. On 2 May 2016, Sophie was found hanging from a bathroom door.

Failure to attend the inquest 

At Sophie’s inquest, held in January 2019, Lawrence was clearly a key witness. He was served with a Schedule 5 notice, requiring him to attend the inquest to give evidence. In response (and saying that he needed to care for his sick mother, in Alaska), he offered to give evidence by Skype. The Coroner agreed to that suggestion, and a video-link test was carried out. However it seems that an impersonator stood in for Lawrence at a preliminary Skype session: his ruse was exposed when the coroner’s staff saw a picture of the real Lawrence in a newspaper[6].

Despite numerous robust reminders from the Court, and the solicitors then acting for him Lawrence failed to give evidence by Skype, and failed to attend the inquest. The written statement he provided was incomplete, and referred to documents which had not been disclosed. As the CPS later put it:

Lawrence showed a flagrant disregard for the inquest and its processes in what was an emotional and difficult time for the Bennett family”

The inquest jury found that Sophie had been unable to cope with all of the events and changes instigated and that this contributed to her death. The jury found neglect on the part of the RPFI as the organisation managing Lancaster Lodge.

The fine

At the end of the inquest, the Assistant Coroner turned to the rarely used sanction under Schedule 6 part 6 CJA. At a hearing on 1 May 2019 he fined Lawrence £650 for failing to attend the inquest[7].

At the family’s instigation the Coroner also referred the matter to the police and CPS for investigation of whether Lawrence had committed any offence under paragraph 7(1)(b) and/or paragraph 7(2)(a) of Schedule 6 CJA which relate to preventing evidence or a document from being given, and/or intentionally suppressing documents known or believed to be relevant to an investigation.

The prosecution

On 16 August at the Magistrates’ Court Lawrence admitted the charge related to withholding evidence/documentation from the inquest, conceding that he was “100 per cent guilty”. He was warned he faced a real prospect of a prison term when sentenced.

However at the sentencing hearing, and now represented by counsel, Lawrence requested an adjournment suggesting there was “potentially an issue with double jeopardy” given he had already been fined by the coroner.

The judge gave Lawrence 7 days to formally apply to withdraw the guilty plea.


Update: 30 October 2019

It now appears that Lawrence’s ‘double jeopardy’ defence was never relied upon. On 30th October 2019 Lawrence appeared (now unrepresented) at the Magistrates’ Court once more when he was was convicted and sentenced to four months imprisonment.

Sentencing him district judge Andrew Sweet said: ‘There is a good reason why people should attend or provide documents to a coroner when carrying out such an inquest, and that is expected to be done with full co-operation and without delay. You frustrated that process'[8].



[1] In 2000 a consultant anaesthetist was jailed for four months after lying to an inquest about his treatment of a terminally ill woman. http://news.bbc.co.uk/1/hi/health/1066210.stm

[2] https://www.theguardian.com/society/2019/feb/07/care-home-chaos-contributed-to-teens-death-inquest-rules

[3] https://www.mylondon.news/news/west-london-news/neglect-poor-leadership-richmond-care-15803252

[4] https://www.inquest.org.uk/sophie-bennett-lawrence-hearing1

[5] https://www.inquest.org.uk/sophie-bennett-prosecution1  NB: There is no connection between the Richmond Fellowship and the RPFI. The founder of the Richmond Fellowship is associated with RPFI but has had no involvement in the operations or direction of the Richmond Fellowship since 1991.

[6] https://www.standard.co.uk/news/crime/care-home-clinician-used-impersonator-to-speak-to-coroner-over-teen-s-death-at-lancaster-lodge-in-a4216216.html

[7] Lawrence did not attend that hearing and declined a request to complete a HMCTS Statement of Means. The reasons why the maximum fine of £1000 was not then imposed are unclear.

[8] See press report here