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You are here: BAILII >> Databases >> England and Wales High Court (Administrative Court) Decisions >> Lepage, R (on the application of) v HM Assistant Deputy Coroner for Inner South London & Ors [2012] EWHC 1485 (Admin) (30 May 2012) URL: https://www.bailii.org/ew/cases/EWHC/Admin/2012/1485.html Cite as: [2012] EWHC 1485 (Admin) |
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QUEEN'S BENCH DIVISION
DIVISIONAL COURT
Strand, London, WC2A 2LL |
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B e f o r e :
and
HIS HONOUR JUDGE PETER THORNTON QC
(sitting as a Judge of the High Court)
____________________
THE QUEEN (on the application of DONNA LEPAGE) |
Claimant |
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- and - |
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HM Assistant Deputy Coroner for Inner South London |
Defendant |
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- and – |
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Commissioner of Police for the Metropolis - and - Dr Brennan |
Interested Parties |
____________________
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Miss Samantha Leek QC (instructed by Southwark Council) for the Defendant
Edwin Buckett (instructed by E.B. Solomons, Director of Legal Services) for the First Interested Party
(No appearance by the Second Interested Party)
Hearing dates: 3 May 2012
____________________
Crown Copyright ©
His Honour Judge Peter Thornton QC:
This is an application for judicial review of decisions made by HM Assistant Deputy Coroner for Inner South London at an inquest held between 15 February and 3 March 2011. Permission to apply for judicial review was granted on the papers by Nicol J on 10 October 2011.
The inquest concerned the sad death of Stacie LePage. Stacie died on 22 March 2007 at St Thomas's Hospital, London. She was just 18 years of age. It is undisputed that the cause of death was acute cocaine toxicity. The jury, on the coroner's direction, returned a short verdict of accidental death (Box4). That direction and the verdict are not challenged. The jury made brief findings of fact (Box 3).
The IPCC conducted an investigation which concluded that no police officer should be the subject of criminal or disciplinary proceedings.
The inquest was opened and adjourned on 28 March 2007 for further investigation. Pre-inquest reviews took place on 31 July 2009 and 21 April 2010. The inquest was resumed and concluded on 3 March 2011.
Before us the claimants were represented by Mr Adam Straw of counsel. The coroner was represented by Ms Samantha Leek QC. The Commissioner of the Metropolitan Police was represented by Mr Edwin Buckett of counsel. I am grateful to all of them for their very helpful submissions, both written and oral.
The claimants raised three main issues: (1) the failure of the coroner to call Dr Deryk James, a forensic pathologist, instructed by the claimants; (2) the failure of the coroner to call evidence of police training about custody procedures including restraint and collapse, and (3) the failure of the coroner to leave three 'disputed factual issues' to the jury.
The defendant coroner (the coroner) submits that she had a power but not a duty to call Dr James. She submits that the evidence of Dr James added nothing to the medical experts who were called, that his reports did not suggest that restraint or search were causative of death, and that she exercised her discretion not to call him reasonably and fairly.
I have considered all of these submissions with care, in the light of the material put before us, which is considerable. We have had the benefit of full written and oral submissions from all concerned. In the end I am not persuaded by the claimants' arguments. In my judgment the claimant's case that the coroner acted unlawfully does not succeed. These are my reasons.
(1) The evidence of Dr Deryk James
"(1) In my view Stacie died as a result of cocaine toxicity which may have been exacerbated by the physical and mental consequences of arrest, restraint and body searching … I think that the risk of death occurring would have been generally increased by any struggle, restraint or mental stress (fear, anxiety) that occurred during the period of toxicity.
(2) I do not think it is possible, either at the criminal or civil standard of proof, to conclude that any specific action or inaction on the part of Police or Dr Brennan, contributed to death.
(3) [Considering Stacie's management by the police and Dr Brennan] I can see in the statements no action that – to me – was clearly dangerous and unjustifiable …
(4) The post mortem examination found no evidence of the application of grip holds or other injuries that might denote restraint or struggle …
(5) [Considering restraint, struggle, fear and anxiety] Clearly there is significant speculation involved in attributing to any one of these factors a causal role …"
"In my opinion the severe, treatment resistant, seizures seen in this patient were due to cocaine toxicity and this was the cause of the patient's death. The cardiac arrest that the patient experienced could either have been directly related to cocaine toxicity, or have occurred as a result of hypoxia/acidosis due to the patient's seizure activity."
In evidence he considered that a drug such as cocaine
"raises the level of the transmitters in the blood that causes anxiety, [but] the additional activity that you see is clinically irrelevant, because you have already got such significant overdrive of those symptoms that additional anxiety is not of relevance …"
"In my opinion, having considered the information currently provided to me, I do not believe that the transfer of Stacey Le-Page to a cell, following her apparent 'collapse' at Lewisham Police Station for the purposes of a strip search, with the restraint/handcuffing that this search entailed, would have had any significant impact on the final outcome."
(2) Discretion, power and duty
"The coroner has a wide discretion – or perhaps more appropriately a wide area of judgment – whom it is expedient to call. The Court will only intervene if satisfied that the decision made was one which was not properly open to him on Wednesbury principles."
"Hence the coroner, and no-one else, decides which witnesses can give relevant evidence, and hence shall be called. This applies to the production of documents as to the giving of oral evidence. And notwithstanding that there may be an obligation at common law for all persons able to give evidence to attend at the inquest, it is still for the coroner, on the basis of 'expedience', to decide who should be examined."
(3) Power and discretion to be exercised reasonably and fairly
"The matter therefore comes down to whether the coroner's judgment that fuller investigation was not required in the circumstances was a lawful judgment. In the context of the sufficiency of an investigation under Article 2 it seems to me that the court, rather than simply asking whether the coroner's judgment was reasonably open to him in the Wednesbury sense, must form its own judgment on whether more was required, in particular by way of independent expert evidence. In forming such a judgment, however, the court must take account of its own lack of medical expertise and must pay an appropriate degree of deference to the judgment of the coroner, who is more experienced in these matters and was closer to the actual evidence in the case."
(4) Evidence about police training
(5) The three issues
For these reasons the application fails. Lord Bingham explained in Middleton that 'it must be for the coroner, in the exercise of his discretion, to decide how best, in the particular case, to elicit the jury's conclusion on the central issue or issues' (202C). He added that 'the choice [of how to elicit that conclusion] must be that of the coroner and his decision should not be disturbed by the courts unless strong grounds are shown' (202E). For my part I find no good reason for interfering with the approach which the coroner took.