Post-inquest allegations of foul play must have some foundation

Farrell v Senior Coroner North East Hampshire [2021] EWHC 778 (Admin) 30.3.21

In this strongly worded dismissal of a s.13 application the Divisional Court (including the new Chief Coroner) were perhaps signalling to Coroners that, whilst there may be an understandable wish to placate the bereaved, detailed consideration should be given before lending one’s support to an application for a fiat for a fresh inquest. A fresh inquest cannot be justified simply to allay concerns of a member of the bereaved family, particularly where a reinvestigation would cause unwarranted distress to another.

When a family member raised suspicions of foul play – albeit with no real evidence in support – the Senior Coroner positively supported the application to the Attorney General for a fiat to apply to quash his documentary inquest into a mesothelioma death.[1] That stance was likely to have been influential in the fiat being given.

The Divisional Court have, however, now roundly dismissed the subsequent s.13 application on numerous grounds. Not only because of the lack of any evidence of the foul play being alleged, but importantly also noting that:

  • A fresh inquest 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 a family member be given a platform to air unjustified suspicions.

The background

Mr Farrell died from mesothelionma having been exposed to asbestos working as a fitter’s mate. When his documentary only inquest in 2016 recorded his cause of death as ‘mesothelioma’ it seemed an uncontroversial point.

However, sometime after the inquest his mother, a retired nurse, raised a matter that had not been put before the coroner. Mrs Farrell asserted that there should be an investigation into whether Mr Farell’s wife had hastened his death by deliberately giving him inappropriate medication, motivated by personal financial gain.

The couple had been married only a few months before his death in a hastily arranged ceremony when he was already extremely unwell, albeit they had by then been in a relationship for over 8 years. A GP had certified that Mr Farrell understood the nature and purpose of his marriage at the time and his parents had attended the ceremony held (with appropriate dispensation) at his home in February 2016. Mr Farrell also made a new will on his marriage which his mother and father witnessed without seeing its contents.

When Mr Farrell died in late October 2016 there was no post-mortem examination. This is of course not unusual where there is an ‘in life’ histological and clinical confirmation of a diagnosis of mesothelioma. Indeed, not only was it the Senior Coroner’s usual practice to proceed without a post-mortem where there was a confirmed diagnosis and the patient was attended in his final illness, but here Mr Farrell’s GP had, in accordance with Mr Farrell’s wishes, actually discussed and confirmed this with the coroner a few days before Mr Farrell died.

The post-inquest allegations

In early 2017 Mr Farrell’s daughter from an earlier relationship contacted the coroner expressing concerns about his “sudden death” and the lack of toxicology reports. It seems she was surprised because her father had kept her wholly unaware of his condition. The (incorrect) suggestion was made that it was his wife who had sought to avoid the post-mortem. Mr Farrell’s mother then followed this by making an allegation to the police that Mr Farrell may have been poisoned and asked them to investigate. The police however took the matter no further. They did not interview his wife or raise his mother’s allegations with her.

When the Claimant applied to the Attorney General for a fiat so she might seek a fresh inquest the Coroner supported her application. Stating “on the information now available I would support the request for a fresh inquest although I think Mrs Farrell needs to understand that the cause of death and conclusion are unlikely to alter. However, for my part I believe there may have been insufficiency of enquiry in the light of what the family now say and there should be a new Inquest”, adding that the issue of “drug involvement” had not been raised at the time of the inquest, and if it had been he would have inquired into the suggestion, although he doubted it would have made any difference to the outcome “bearing in mind the history.”

It seems that the Claimant’s  suspicions were largely based upon: the hastily arranged marriage and making of a new will on a day when, she now alleged, Mr Farrell was disorientated, bewildered, lethargic and uncommunicative; that in June 2016 Mr Farrell had allegedly raised questions about his prescribed medication with his mother; his dramatic deterioration at the beginning of October 2016; her assertion that it was unusual to request not to have a post-mortem; the large quantity of end of life medication left to be returned to the local pharmacy after his death which she suggested was for euthanasia; that his wife had closed his bank accounts and transferred his money to her own accounts on receiving the death certificate.

Unsurprisingly, his widow unequivocally rejected any suggestion that she improperly or maliciously administered any inappropriate medication to her husband at the end of his life; and categorically stated that she only gave him medication in accordance with what was prescribed by his doctors. She said there was nothing suspicious about his executing a will on his marriage leaving substantial specific bequests to his children and grandchildren with the residue to his wife. There was nothing suspicious about closing his bank accounts as that and all other aspects of probate were conducted by her as one of two co-executors of his will.

No medical support for the allegations

The Court had before it an expert review of Mr Farrell’s medical records by Professor Britton, a retired consultant physician. He stated that the diagnosis was unquestionable and it was abundantly clear that in those last few weeks the end of life was imminent and preparation for it was made with appropriate medication. Respecting Mr Farrell’s wish not to have a post-mortem was entirely appropriate from a medical perspective, as was the inquest conclusion as to the cause of death. At the time of his death there was no reason to believe that a toxicological examination was necessary given the nature of his condition and that his death from his mesothelioma was imminently expected by all his healthcare professionals. There was nothing surprising about the quantity of medication found at Mr Farrell’s home at the time of his death.

The suspicions had no foundation

Faced with that evidence the Divisional Court unsurprisingly concluded, “without any real hesitation”, that there was no realistic possibility of a fresh inquest reaching a different conclusion or finding that there was anything in the Claimant’s suspicions.

All the evidence showed the suspicions to be without any real foundation and, even taken at their highest and cumulatively, they were not realistically capable of supporting the allegations made. Moreover, the suggested financial motive attributed to his wife made little sense: there would be no real financial motive for someone who had been his partner for over 8 years to hasten Mr Farrell’s passing by a matter of days in the absence of any suggestion or grounds for thinking that his financial dispositions might change in that period.

For a number of reasons it was clearly not in the interests of justice for a fresh inquest to be held: there could be no new toxicology report or any new empirical data with no surviving tissues or blood samples; a fresh inquest would have no more than the witness and documentary record currently available; to permit a reinvestigation would cause unwarranted distress to the widow by the continued public airing of the serious allegations being made against her; similarly, distress may be caused to the 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 did not require a platform to be given to unjustified suspicions. A fresh inquest cannot be justified simply to allay concerns of members of the bereaved family irrespective of the possibility of a different outcome.

Moreover, judging by the ‘misguided passion’ with which the Claimant advanced her suspicions, and her maintenance of arguments flatly contradicted by the contemporaneous records, the court feared that she would no more be satisfied by their rejection at a second inquest than she was with the fact they were not considered at the inquest which had taken place.

The clear message is that, despite the previous Senior Coroner having conceded to the Attorney General that “there may have been insufficiency of enquiry in the light of what the family now say“, it will not be an insufficient inquiry where a Coroner does not investigate an allegation that has no proper evidential foundation.



[1] By the time the High Court application was made there was a newly appointed Senior Coroner who remained neutral on the issue.