Nicholls v Coroner for City of Liverpool: Admn 8 Nov 2001

As the deceased was arrested he swallowed something. He was examined by a doctor and denied that he had swallowed drugs, but his condition deteriorated and he died at hospital. The coroner refused to admit the evidence of a professor who was highly critical of the conduct of the doctor who had seen the deceased, and said that an antidote should have been prescribed. The coroner found insufficient evidence of neglect to leave that issue to the jury, and they returned a verdict of death by misadventure.
Held: The professor should have been called even though it might well have led to a further adjournment ‘measured in weeks or perhaps one to two months’. The coroner’s principal reason for refusing to call the professor was that his report was concerned on its face not with neglect applying the Jamieson test, but with medical negligence applying the Bolam test, ‘Notwithstanding Mr Burnett’s submission that neglect and negligence are two different ‘animals’, there is, in reality, no precise dividing line between ‘a gross failure to provide . . basic medical attention’ and a ‘failure to provide… medical attention’. The difference is bound to be one of degree, highly dependent on the facts of the particular case. . . . Standing back and looking at the facts of the present case, one starts with a death in custody. As the then Master of the Rolls said in Jamieson, such deaths rightly arouse acute public concern. Professor Redmond’s report stated that this death in custody was ‘entirely preventable’ by steps that could have been expected of any doctor acting to a reasonable standard. . . . Such a statement in respect of the death of a person in custody pointed to a need for the fullest investigation. The steps that Professor Redmond was suggesting would have been taken by any doctor acting to a reasonable standard were neither complex nor sophisticated. They amounted to doing no more than checking the patient’s respiratory rate and the arranging for it to be checked after about another hour, rather than simply leaving the patient until the next morning . . . So far as causation is concerned … in my judgment it is important not to read the Master of the Rolls words in Jamieson as though they were contained in an enactment, or to apply them in an over literal manner.’
Application for judicial review of coroner’s decision on behalf of child daughter of deceased. He had died in police custody having taken opiates. The coroner had refused an adjournment for the family to call expert evidence as to the proper treatment of such a patient.
Held: The coroner’s reasons for not allowing the adjournment for the evidence did not stand up. As a death in police custody, it required a full public examination. That had not been done, and the verdict of misadventure was quashed and a fresh inquest was ordered.


Rose LJ, Sullivan J


[2001] EWHC Admin 922, [2001] EWHC 922 (Admin), [2001] Inquest LR 249, [2002] ACD 13




Coroners Act 1988 13


England and Wales


CitedLadd v Marshall CA 29-Nov-1954
Conditions for new evidence on appeal
At the trial, the wife of the appellant’s opponent said she had forgotten certain events. After the trial she began divorce proceedings, and informed the appellant that she now remembered. He sought either to appeal admitting fresh evidence, or for . .

Cited by:

CitedKhan, Regina (on the Application of) v HM Coroner for West Hertfordshire and Another Admn 7-Mar-2002
The deceased died in police custody. The coroner refused to leave to the jury possible verdicts of unlawful killing, or death contributed to by neglect, or breach of his right to life. He adjourned the hearing to allow this challenge.
Held: . .
CitedRegina on the Application of Mullholland v HM Coroner for St Pancras QBD 7-Nov-2003
The applicant sought to re-open a coroner’s inquest. The deceased had been drunk, slipped banged his head and fallen to the ground. Police and ambulance were called. The ambulance worker was not told he had been unconscious, and he was taken to the . .
Lists of cited by and citing cases may be incomplete.


Updated: 06 September 2022; Ref: scu.432775