The deceased had gone to hospital and was diagnosed as having a kidney stone. As it was removed there was evidence of infection. She declined and was transferred to the local NHS hospital in intensive care. She died and a post-mortem identified gram-negative septicemia where bacillae had infected the blood stream. The coroner saw nothing in the reports to indicate that anything less than approriate treatment was provided for a rare but critical condition.
Held: ‘Section 13 contains a freestanding power to order a new inquest ‘where . . the discovery of new facts or evidence or otherwise [makes it] necessary or desirable in the interests of justice.’ There was now evidence to show that death was not inevitable from the condition described. ‘The family, in such cases, are entitled to a full inquiry into how and why the death occurred. ‘ They had not had that enquiry, and a new inquest was ordered.
Tuckey LJ, Field J
 EWHC 3071 (Admin)
Coroners Act 1988 13
England and Wales
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – In re Rapier (Deceased) QBD 1988
A young prisoner had been found dead in his cell hanging. A report suggested that he may have been sniffing solvents. The coroner himself initiated proceedings both under the Coroners’ Act and for judicial review to quash the inquisition over which . .
Cited – O’Reilly v Coventry Coroner QBD 3-Apr-1996
The inquest was said to have been flawed because relevant material was withheld from the jury, factual issues were not addressed, and the Coroner had refused to leave open the possibility of a verdict of lack of care or neglect. The deceased had . .
Cited – Jones v HM Coroner for The Southern District of Greater London and Another Admn 28-Apr-2010
The mother of the deceased asked for a new inquest, saying that there had been insufficient enquiry. He was an adult suffering Asperger’s syndrome and other difficulties, but had sought and been given excess prescriptions of fentanyl a drug to . .
Lists of cited by and citing cases may be incomplete.
Updated: 25 October 2021; Ref: scu.226918