Administration of justice – Pharmaceuticals – Inquests – Public interest

Glennys Jones (applicant) v HM Coroner for the Southern District of Greater London (respondent) and Deshminder Virdi (interested party): DC (Lord Justice Toulson, Mr Justice Owen): 28 April 2010

The applicant (J) applied for an order quashing an inquisition in respect of the death of her son (D) and directing that another inquest be held by a ­different coroner.

D suffered from Asperger’s syndrome and Crohn’s disease. He was registered with the interested party general practitioner and had been prescribed fentanyl, an opioid painkiller, and other medication, having already been prescribed fentanyl and morphine by out-of-hours doctors’ services three times during the preceding week. He was found dead in bed. Toxicology tests revealed fentanyl levels of 15 to 20 times the fatal average dose and a pathologist confirmed the cause of death as fentanyl toxicity. An inquest was held and the respondent coroner delivered an open verdict. The coroner referred to the unexplained question of how D had come into possession of sufficient fentanyl to achieve such a high blood level. Further investigations instigated by J, including one carried out by the relevant primary care trust (PCT), had resulted in recommendations being made to doctors and other health professionals regarding fentanyl and procedural issues in relation to repeat prescriptions. J had discovered that a warning had been issued by the manufacturers of fentanyl in the US following a review of fatalities linked to the drug. J claimed that because of the insufficiency of the inquiry and the new evidence available regarding fentanyl, it was necessary and in the interests of justice that another inquest be held. J contended that (1) the inquest had failed to discharge its primary function of investigating fully the means by which D died, and that if a full and proper investigation had been undertaken, a verdict of accidental death would have been possible; (2) there was a wider public interest in fully investigating how D came to die from fentanyl toxicity given the evidence that there had been a considerable number of deaths in the US and the UK linked to unintended overdoses of fentanyl.

Held: (1) There was substance to the argument that there had been insufficient inquiry. The coroner had taken a narrow view of the scope of the inquest and had been satisfied that his duty to address the question of how D came to die was discharged by establishing that it was due to a fatal dose of fentanyl. He had identified the central question, namely how D came to have such a high concentration of fentanyl in his blood, but failed to investigate the answer to it, apparently on the basis that the question could not be answered other than by making the assumption that D had come into possession of an additional supply from an unknown source. There was no basis for such an assumption. A full and proper investigation into the means by which D died would have involved investigating in particular whether the quantity of fentanyl prescribed and apparently used could have been fatal in certain circumstances and, if so, whether such circumstances were present. If that quantity could have been fatal, it would have been necessary to inquire into how and why D was repeatedly prescribed fentanyl. It might well be that, had the coroner been aware of the further information regarding fentanyl, he would have appreciated that it might have been possible to answer the central question and taken a different view as to the scope of the inquiry. There had been an insufficiency of inquiry and there was the possibility of a conclusion of accidental death if a further inquest was held, R v HM Coroner for North Humberside and Scunthorpe Ex p Jamieson [1995] QB 1 CA (Civ Div), and R v HM Coroner for Inner London West District Ex p Dallaglio [1994] 4 All ER 139 CA (Civ Div) applied.

(2) In the light of the further information regarding fentanyl, there was a wider public interest in a full inquiry into the means by which D had died. Such an inquiry would address a number of issues. In particular, the degree to which the medical profession at large was alive to the possible danger to life presented by the prescription of fentanyl. Also, the circumstances in which D came to be given repeat prescriptions over a very short period of time, apparently on demand, and in the case of the out-of-hours services, without reference to D’s medical records, were of obvious public concern. Although those issues had been addressed in the investigation by the PCT, that investigation had not been conducted in public. It was necessary in the interests of justice that another inquest should be held. The scope of that inquest would be for the presiding coroner to determine and, although it would also be a matter for the coroner, it appeared that the further inquest should be held with a jury. The inquisition was quashed and a further inquest ordered.

Application granted.

Nicholas R D Brown (instructed by Colemans-ctts) for the applicant; Paul Matthews (solicitor-advocate) (instructed by Withers) for the respondent.