Inquest background

Zoe Morrow, 41 years old, had been found dead in her bedroom in April 2021, from mixed drug toxicity. She was being treated for bipolar disorder and depression by Mersey Care NHS Foundation Trust ('the NHS Trust'). The NHS Trust's investigation had identified learning and 'gaps' in Zoe's care, but concluded that these did not cause her death.

The inquest took place in March 2022, heard by Assistant Coroner Graham Jackson. He called two live witnesses - his Coroner's Officer and a Quality Matron from the NHS Trust, to speak to the findings of the Trust's investigation. The Coroner concluded the inquest by way of the short-form conclusion of drug-related death. He stated that he would not conclude 'suicide', because he did not have sufficient evidence of Zoe's intentions. The Coroner encouraged the family to raise their concerns about the care with the NHS Trust directly, as he decided those were outside the scope of the inquest.

Ms Morrow's brother made an application for a fresh inquest to be held under section 13 Coroners Act 1988. The family submitted the following:

• They had not been allowed to give evidence or question witnesses about Zoe's NHS treatment in the months before her death
• There were procedural failings, and
• The family had not been given the opportunity to argue for a conclusion of suicide

The High Court's conclusions

The High Court stated that "the Coroner decided to limit the scope of this inquest to the circumstances immediately surrounding Zoe's death, namely, how she came to be found dead on the floor of her bedroom on 12 April 2021. He was not going to investigate whether there had been failings in Zoe's care by the Trust, or look at whether any such failings might have contributed to Zoe's death". The High Court concluded this was a proper and lawful exercise of the Coroner's discretion.

In relation to a potential finding of suicide, the High Court identified the central dispute as being whether Zoe was 'actively planning' suicide in the months before her death, rather than 'merely considering suicide'. Zoe had expressed threats to end her life previously, had made previous attempts and had asked others to look after her animals. However, no last 'note of intent' was found and the NHS treating clinicians did not think Zoe was planning to kill herself. Essentially, there was evidence which pulled in both directions. The High Court concluded that the Coroner was "not in a position to resolve the dispute… because that dispute (and the evidence about it) lay outside the narrow scope of this inquest" and it was reasonable for the Coroner to conclude that Zoe's death was 'drug-related'. The High Court noted that the Coroner's conclusion of drug-related death did not exclude the possibility that Zoe took her own life, nor did it exonerate the Trust in any future proceedings.

The Court held that the Coroner was entitled to call the witnesses he chose and admit and read the other evidence (under Rule 23 Coroners (Inquest) Rules 2013).

Of note, there was an allegation of 'collusion between the Coroner and the NHS Trust'. The High Court 'read all of the correspondence' and the transcript of the inquest carefully, and found no evidence of collusion.

Impact

This is a judgment which supports legal submissions and coronial decisions for a narrow scope and a short witness list, to really focus on 'how the death occurred'. This is one in a number of recent decisions, which appear to embody the message from Morahan - "An inquest remains an inquisitorial and relatively summary process. It is not a surrogate public inquiry".

We note of course that Coroners enjoy a broad discretion, and therefore the scope set by individual Coroners will vary. If seeing this variety in the scope of such inquests attracts concern from interested persons across the country, we may see future High Court decisions on this point.

How we can help

Our large national team of inquest lawyers have a wealth of experience in supporting providers and individuals across the health and social care sector through the inquest process - from relatively straightforward hospital deaths to very complex Article 2/jury inquest cases involving multiple parties and deaths in state detention, including providing representation at pre-inquest review hearings when matters such as inquest scope are decided.