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England and Wales High Court (Administrative Court) Decisions
You are here: BAILII >> Databases >> England and Wales High Court (Administrative Court) Decisions >> Dowler, R (on the application of) v Coroner for North London  EWHC 3300 (Admin) (06 November 2009)
Cite as:  ACD 18,  EWHC 3300 (Admin), (2010) 11 BMLR 124
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QUEEN'S BENCH DIVISION
THE ADMINISTRATIVE COURT
B e f o r e :
|THE QUEEN ON THE APPLICATION OF DR DOWLER||Claimant|
|CORONER FOR NORTH LONDON||Defendant|
WordWave International Limited
165 Fleet Street, London EC4 2DY
Tel No: 020 7404 1400 Fax No: 020 7831 8838
(Official Shorthand Writers to the Court)
The Defendant was not represented, did not attend
Crown Copyright ©
"13 Order to hold inquest
(1) This section applies where, on an application by or under the authority of the Attorney-General, the High Court is satisfied as respects a coroner (the coroner concerned) either —
(a) that he refuses or neglects to hold an inquest which ought to be held; or
(b) where an inquest has been held by him, that (whether by reason of fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, the discovery of new facts or evidence or otherwise) it is necessary or desirable in the interests of justice that another inquest should be held.
(2) The High Court may —
(a) order an inquest or, as the case may be, another inquest to be held into the death either —
(i) by the coroner concerned; or
(ii) by the coroner for another district in the same administrative area;
(b) order the coroner concerned to pay such costs of and incidental to the application as to the court may appear just; and
(c) where an inquest has been held, quash the inquisition on that inquest.
(3) In relation to an inquest held under subsection (2)(a)(ii) above, the coroner by whom it is held shall be treated for the purposes of this Act as if he were the coroner for the district of the coroner concerned."
"An inquiry which leaves too many questions unanswered and too many issues unresolved is not a sufficient inquiry."
"If the inquest had been so conducted or the circumstances tending to such that there was a real risk that justice has not been done, then there is impairment ..... It is right that the procedure provides that justice is done and is seen to be done. The court ought not to allow the inquisition to stand."
"(a) The urgency of the request for FPS was not made known to hostel staff;
(b) to fail to undertake an FPS emergency in the circumstances amounted to a really serious failure to provide basic medical care. What was obvious was the need for an urgent FPS;
(c) it is well established that diabetic ketoacidosis is a reversible condition provided it is recognised and treated as so."
That led to the coroner's conclusion that on the balance of probabilities the death was contributed to by neglect. He went on to say:
"There is no doubt that this was an avoidable death. Had the test been carried out, his condition would have been recognised."
This was in the absence of any evidence from Dr Dowler.
"I take the view that the family did not have a fair crack of the whip and that the evidence before us should be ventilated before a fresh hearing and preferably a different coroner."
I prefer to state the test in terms of real danger and real likelihoood to ensure that the court is thinking in terms of possibility rather than probability of bias."
He went on to say that -
"The court should ask itself whether, having regard to those circumstances, there was a real danger of bias on the part of the relevant member of the tribunal in question in the sense that he might unfairly regard or have unfairly regarded the claimant ..... the case, this part of the issue under consideration by him."