Source: All England Reporter
Publisher Citation: [2005] All ER (D) 246 (Nov)
Court: Queen's Bench Division (Divisional Court)

Gage LJ and Openshaw J

Representation Leslie Thomas (instructed by Farleys, Accrington) for the appellant.
Judgment Dates: 18 November 2005


Coroner - Inquest - Fresh inquest - New evidence - Whether fresh inquest to be ordered.

The Case

Where a patient had died in hospital following a fall it was necessary for there to be a full investigation. A number of questions had to be asked: (i) why did the patient fall; (ii) why were no details of the fall recorded in the clinical notes; (iii) why no bed rail had been used; (iv) might such a precaution been advisable; (v) was there a thorough post mortem; (vi) was the pathologist alerted to the fact that the patient had fallen; (vii) were there any injuries referable to the fall and, if so, did they contribute to his death. It was not necessary to make findings on each of those matters, but it was necessary to have a thorough investigation into the circumstances surrounding the death.

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