The Queen on the Application of Canning v HM Coroner for the County of Northampton [2005] EWHC 3125 (Admin)

This case concerned the application for judicial review by the Claimant, Canning (C) based on the refusal by the Defendant, HM Coroner for Northampton (The Coroner) to hold an inquest into the death of his son (F).

F was a 14 year-old boy and an epileptic quadriplegic.  He suffered with severe cerebral palsy, was blind and without speech.   He could communicate to a limited extent by crying, laughing or smiling and he might scream if he was in pain.

F had become restless and lost his appetite during the daytime whilst in the residential respite care of Northamptonshire Health Care Trust.  He became unsettled, started to sweat and remained restless and tearful into the evening.  He went to bed and appeared to be in pain and was given a paracetamol.  The following morning, F was pale, his lips were slightly cyanosed and his extremities cold and his tongue looked dry.  F was taken to hospital but on route his breathing became shallower and he died before he reached the hospital.

A post mortem examination was carried out and the cause of death was an infarction of the small bowel caused by a condition in which a section of the bowel becomes twisted causing the bowel to become devascularised leading to acute inflammation.   There was also evidence of peritonitis.  The Coroner was asked by C to hold an inquest which she declined to do, indicating that she was satisfied that F had died of natural causes.

Under the s.8 (1) of the Coroner’s Act 1988 where “a Coroner is informed that the body of a person is lying within his district and there is reasonable cause to suspect that the deceased (a) has died a violent or unnatural death …. then whenever the cause of death arose within his district …. the Coroner shall as soon as practicable hold an inquest into the death of the deceased.”  Where there is reasonable cause to suspect that medical neglect, lack of care or other culpable human failure could have contributed to the death, it may fall to be treated as “unnatural” within the meaning of s.8 (1).

C‘s claim was based on grounds that the Coroner’s refusal was unreasonable and irrational according to the dictum of Associated Provincial Picture House v Wednesbury Corporation [1948].  It also relied on Article 2 ECHR that where a deceased died in the care of the state, there was a procedural obligation to investigate.

C’s expert, a Professor in paediatric gastroenterology, believed that it would have been difficult for individuals not familiar with F’s profound and severe disabilities to have interpreted his symptoms, although he felt it would have been prudent for F to have been assessed by someone who was familiar with him.   Furthermore, he stated to C that “if skilled surgery had been available to F at the time he awoke on the morning of his death, on the balance of probabilities, he would have been saved”.

The question for the court was whether the Coroner had reasonable cause to suspect that F died an unnatural death.  A death was unnatural if there was reason to suspect that there was a gross failure to provide medical attention and that the need for such attention was obvious at the time, R Touche v Inner London North Coroner applied.  The court held that the Professor’s view, that it would have been prudent for F to have been assessed, conflicted with evidence that F had had settled periods on the night before he died.  The court concluded that it was impossible to hold that the Coroner arrived at an irrational or otherwise unlawful decision in declining to hold an inquest.    The Coroner had acted lawfully and the application was dismissed.

The court also held that Article 2 ECHR was not engaged where there was no evidence of culpable failure, Goodson v HM Coroner for Bedfordshire and Luton & Dunstable Hospital NHS Trust [2004] EWHC followed.


It seems to the site proprietor that there is a danger of Disability Discrimination if the threshold test of reasonable cause is in practice harder to achieve because the client or patient could not communicate in ordinary terms; if someone non-disabled had been going through that sort of pain and distress, it is inherently less likely that his condition would have been left the extra night.

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