Inquests

Clodagh has appeared before many Coroners and their juries on behalf of families, doctors, NHS Trusts, the police and the prison service as interested persons. Many of her cases have included human rights issues and controversial ethical elements such as the withholding of treatment from elderly patients, proceeding with high risk transplant surgery, deaths of psychiatric patients, including those under ‘section’ and childbirth related maternal and perinatal deaths.

Selected Cases

  • Graham Stoten & 9 others (2018) Clodagh is instructed by Mrs Stoten in this inquest into 10 deaths of patients of urological surgeon, Paul Miller, at East Surrey Hospital, who did not offer Mr Stoten curative surgery for bladder cancer from 2011-2013 and instead pursued experimental treatment options, resulting in his premature death aged 57. Issues of neglect and unlawful killing arise.  Inquest has been adjourned part-heard as Coroner recused herself.
  • Reeta Saidha (2018): represents family at inquest into maternal death of 38 year old woman admitted with spontaneous rupture of membranes at 15 weeks’ gestation and there was a delay in offering or providing termination, including after the development of sepsis.  The deceased went on to develop disseminated intravascular coagulopathy and multi-organ failure and died.
  • Sophie Burgess (2017): represents family at inquest into death of 11 month old baby with a history of febrile seizures who was given a very large overdose of Phenytoin by a hospital doctor, resulting in her sudden cardio-respiratory arrest and death. The issues include how the overdose came to be given and why the drug was given at all, given that the baby was ‘stable’ and despite a nurse challenging doctors about their treatment of the baby. Proceedings were halted on final day of inquest as police are re-opening their enquiries into potential manslaughter charges. A decision is awaited in 2018.
  • Abdul Khan (2016): appeared for the family of a 77 year old man whose kidney dialysis line was malpositioned while he was an inpatient (following a fall), resulting in a haematoma, which was not scanned. Clinicians failed to act upon his deteriorating state, including persistent anaemia (despite 6 units of blood), hypotension, pain and breathlessness. When he was eventually scanned days later, it was misreported, and a retroperitoneal haematoma and bowel ischemia were only diagnosed after he suffered a cardiac arrest, and he later died.
  • Archie Haxell (2015): represented the family at the inquest into the neonatal death of a first-born twin, who died at 5 days’ of age, having sustained a severe brain injury during the neonatal period immediately following his delivery when attention was diverted to the second-born twin. The inquest gave rise to medically complex neuropathological issues about causation. Communication issues were central to the shortcomings identified. The coroner wrote a Prevention of Future Deaths report, in line with Clodagh’s submissions.
  • Maria Lopes (2014): acted on behalf of the Trust in this inquest into the death of a 31 year old woman admitted to hospital with renal colic who developed sepsis, hyperpyrexia of unknown cause and died, despite intensive treatment on ICU over the course of a week. The precise cause of death was unclear, and various expert theories including malignant hyperthermia, Propofol Infusion Syndrome, hypophosphatemia and delayed treatment of sepsis were in issue, in this exceptionally medically complex case.
  • George Werb (2014): represented the family of a 15-year old boy who stepped in front of a train while on home leave from the psychiatric inpatient unit at The Priory Southampton. George was allowed on home leave despite suffering from psychotic delusions and telling staff that he felt ‘very suicidal’. The coroner returned a narrative conclusion, and found that the assessment of George’s suicide risk was incomplete, inaccurate and did not reflect the actual situation.
  • John Moore-Robinson (2014): appeared for the junior doctor in this high profile re-hearing of the inquest into death of 20 year old man admitted to Mid Staffordshire hospital in 2006 after falling over handle bars of his bike. The junior doctor saw the patient and discharged him home, and the patient died later that night of an undiagnosed ruptured spleen. This case was highlighted in the Francis Inquiry because a consultant from A&E wrote a report to the coroner stating that this death was avoidable, but this was omitted from the statement sent to the original coroner. At the re-hearing the coroner concluded that the problems contributing to the missed diagnosis were more systemic, rather than failings of the junior doctor who should have been supervised and if proper triage procedures followed a senior doctor would have seen the patient immediately.
  • James Hernon (2012-2014): appeared for a mental health Trust at inquest into death of man with a long history of psychosis and hallucinations who was admitted to A&E after stabbing himself. He was referred to the psychiatric hospital for assessment and attended voluntarily, but left before being assessed. In the following weeks there were concerns about his mental health but he declined to attend hospital. He hanged himself at home, without having had any medical assessment. Coroner’s expert was discredited to such an extent during questioning that the coroner discharged the jury and instructed a new expert, resulting in a conclusion which made no criticism of the Trust at the resumed hearing.
  • James Fyfe (2013): represented the family at the jury inquest into the death of a 90 year old man admitted to hospital, who fell from an x-ray trolley, suffering a fractured neck and died a few weeks later. The jury was persuaded that there were substantial failings in the trolley maintenance and inspection systems which contributed to the death. There were potential implications for gross negligence manslaughter / corporate manslaughter, with the police and HSE investigating.
  • Diane Henshaw (2013): acted on behalf of a locum staff grade anaesthetist who believed that his 74 year old patient, who was undergoing laparotomy for a possible incarcerated hernia, had an empty stomach; he therefore failed to perform a rapid sequence anaesthetic induction and the patient regurgitated on induction of anaesthesia. She subsequently died, as a result of peritonitis and perforation of the bowel, and aspiration. Clodagh previously represented this doctor before the GMC in respect of Mrs Henshaw’s case, and the GMC Panel found the facts in favour of the doctor and made no finding of impairment of fitness to practise. The coroner made no pejorative findings against the doctor either.
  • Michael Longley (2013): Clodagh represented an out-of-hours GP in complex haematological case re post-operative anti-coagulation of a patient who was ultimately admitted to hospital having suffered a subdural haematoma. He had thrombocytopenia and died later that day, probably as a result of a previously unrecognised complication from anticoagulation.
  • Daniel McMahon (2013): represented the mental health Trust in this inquest into the death of a 28 year old ‘sectioned’ psychiatric inpatient, following an admission for a psychotic episode which began while on holiday abroad. He was on s.17 MHA accompanied leave, when he jumped in front of a train, suffering fatal head injuries. There were multiple issues about the adequacy of the psychiatric care, as well as concerns about the response of police and Network Rail to a 999 call before the collision. Clodagh persuaded the coroner that there were no issues for the jury to determine in relation to the Trust.
  • John Shircliff (2013): acted for staff grade haematologist in relation to death of a patient following a total knee replacement, who had his pre-operative assessment 6 months earlier. The blood results were abnormal and no action was taken to repeat them. On the day of surgery it was not appreciated that he was anaemic. Post-operatively, it was found that he had an aggressive form of leukaemia. No criticism was made of Clodagh’s client.
  • Kimberley Harrison (2012): acted on behalf of a junior GP at an inquest into the sudden death of a 15 year old girl as a result of undiagnosed cardiac complaint less than 10 hours after being seen by her in a walk-in centre feeling generally unwell. Despite concerns of the family, it was established through the factual and expert testimony that no justifiable criticisms could be made of the GP. The Coroner found that the death was unavoidable.
  • John Downey (2011): represented prison GP in inquest into hanging of remand prisoner, where issues arose about similar fact evidence from another inquest and Ikarian Reefer arguments about one of the experts.
  • Henry Healey (2010-2011): appeared for family in Inquest into death of a baby with a fractured skull and consequent brain damage caused by obstetrician’s digital pressure applied during a Caesarean section delivery. Coroner returned a long narrative verdict raising substantial concerns about the medical care, in particular by the obstetrician.
  • Marcus Cottoy (2011): acted for junior psychiatrist at inquest into death of patient in police custody who had been sectioned and was in the process of being admitted to a psychiatric hospital as he was exhibiting very disturbed behaviour.
  • Patrick Bennett (2010): appeared on behalf of Trust in inquest re death of compulsory psychiatric inpatient (under s.3 MHA 1983) from medication overdose, who lacked capacity to comprehend the implications of taking excessive medication or to form any suicidal intent. Third party involvement queried and criminal investigation contemplated by coroner. Complicated toxicology evidence.
  • Roderick Smyth (2010): represented the family – death following live donor kidney transplant where patient was suffering from active infection in toes pre-operatively and guidance suggested that the elective surgery should not have proceeded.
  • R v Anderson ex p HM Coroner for Inner North London [2004] EWHC 2729 (Admin): unlawful killing verdict in Roger Sylvester case quashed by Collins J as coroner’s direction to jury on causation so confusing as to render verdict unjust.
  • Roger Sylvester (2003): appeared on behalf of the Commissioner of Police – sensitive case following the death of a black man suffering from cannabis induced delirium who was restrained by police at a psychiatric hospital and died whilst being restrained.
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