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Cite as: [2000] EWHC Admin 359

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H.M. CORONERS COURT OF ST PANCRAS and H.M. CORONER FOR INNER NORTH LONDON DISTRICT, R v. [2000] EWHC Admin 359 (22nd June, 2000)

Case No: CO/4347/99 & CO/0505/00

IN THE SUPREME COURT OF JUDICATURE
COURT OF APPEAL (QUEEN'S BENCH DIVISION)
DIVISIONAL COURT
Royal Courts of Justice
Strand, London, WC2A 2LL
Thursday 22nd June 2000

B e f o r e :
LORD JUSTICE KENNEDY
and
MR JUSTICE MORISON

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	R -V- H.M. CORONERS COURT OF ST PANCRAS
	- and -
	R -V- H.M. CORONER FOR INNER NORTH LONDON DISTRICT

Ex parte TOUCHE
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(Transcript of the Handed Down Judgment of
Smith Bernal Reporting Limited, 180 Fleet Street
London EC4A 2HD
Tel No: 0171 421 4040, Fax No: 0171 831 8838
Official Shorthand Writers to the Court)
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Philip Havers QC (instructed by Messrs Alexander Harris for the applicant)
Terence Coghlan QC and Ben Collins (instructed by Hempsons for the respondents)

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Judgment
As Approved by the Court
Crown Copyright ©

LORD JUSTICE KENNEDY:

This is a judgment of the Court
1. Introduction
We have before us an application for Judicial Review of the refusal of H.M. Coroner for Inner London North District to hold an inquest touching the death of Laura Touche, and an application under section 13 of the Coroners Act 1988 for an order that an inquest be held. It is common ground between counsel that the second application adds nothing of significance of the first, so the case has been argued and will be dealt with in this judgment as an application for Judicial Review.
2. Circumstances of Death.
Mrs Touche was admitted to the Portland Hospital, London at 6.45 pm on Saturday 6th February 1999 when she was pregnant with twins. She had had a normal pregnancy, there had been spontaneous rupture of membranes, and it was decided to deliver the twins by caesarean section. They were satisfactorily delivered at 10.24 and 10.25 pm. Her blood pressure post delivery was recorded as 120/60. We are told that the normal blood pressure for a young adult would be 120/80 and the figures recorded at this early stage gave no cause for concern. At 11 pm Mrs Touche was transferred from the labour ward. According to the nursing notes she complained from the outset of headache. At 1.35 am she said that it was severe, she was feeling unwell and nauseated and she looked worried. Her blood pressure then was 190/100. At 1.40 am she was seen by the resident medical officer on call, and by the night sister, and thereafter she was observed and her blood pressure was taken every 10 to 15 minutes. For present purposes we need not set out all of the readings but at 1.55 am it was 200/100, and at 2.40 am it was 181/99 and a drug named nifedipine was administered which by 2.55 am had reduced the blood pressure reading to 112/75. Between 2.55 and 5.30 am her blood pressure ranged between 108/81 and 142/82. Those readings are described by Professor Rubin as satisfactory, but the patient vomited repeatedly, and her neurological symptoms progressed. By 4.20 am her speech was slurred, she was cold and clammy and looked unwell. Muscle tone was reduced in the left arm and leg, and power was absent. She was then transferred to the Middlesex Hospital, and from there to the National Hospital for Neurology and Neurosurgery at Queen Square where she died on 15th February 1999.
A post-mortem examination by Professor Scaravilli on 18th February 1999 confirmed the diagnosis of a sub-acute intra cerebral haemorrhage. It was in the right basal ganglia and was consistent with the clinical history of eight days duration. The site was typical of haemorrhages occurring secondary to hypertension, and there was observed at post mortam examination mild degenerative vascular pathology in the same region, which "may have predisposed to hypertensive haemorrhage following delivery." There was no histological evidence of eclampsia. Professor Scaravilli recorded the cause of death as -
"1a Brain swelling and tonsillar herniation
1b Intra Cerebral haemorrhage
2 Recent pregnancy"

3. When an Inquest must be held
The law as to when an inquest must be held is set out in section 8(1) of the Coroners Act 1988 which, so far as material, reads as follows -
"Where a coroner is informed that the body of a person ("the deceased") is lying within his district and there is reasonable cause to suspect that the deceased -
(a) has died a violent or an unnatural death:
(b) has died a sudden death of which the cause is unknown: or
(c) has died in prison or in such a place or in such circumstances as to require an inquest under any other Act,
then, whether the cause of death arose within his district or not, the coroner shall as soon as practicable hold an inquest into the death of the deceased ......"
As was pointed out by the Court of Appeal in R v Poplar Coroner ex parte Thomas [1993] QB 610 at 626 F there is no general discretion for the coroner to hold an inquest. An inquest can only be held in a case which falls within section 8(1) but in any such case, subject to an exception which for present purposes is not material, an inquest must be held.
In the present case, as in Thomas, no one disputes the pathologist's assessment of the cause of death as a proper discharge of his pathological function. It thus soon became clear, from the pathologist's report and from the known history which we have already summarised, that Mrs Touche did not die a violent death, or a sudden death of which the cause was unknown. Section 8(1)(c) did not apply to the circumstances of her death, so there could be an inquest only if there was reasonable cause to suspect that she died an unnatural death (section 8(1)(a). That begs the question of how for this purpose an unnatural death is to be defined, which was the question which the Court of Appeal had to address in Thomas. Having put on one side violent deaths, for which the statute expressly provides, Dillon LJ at 627 C sought to identify classes of non-violent death which are to be regarded as unnatural. He referred to deaths arising as a result of industrial illness, typhoid caused by contamination of the water supply, Legionnaires' Disease, or lack of care "in the narrow and somewhat technical sense in which that term was interpreted by the Divisional Court in R v Suffolk Coroner ex parte Hicks [1987] 1 WLR 1624". That approach was no doubt helpful, but in reality it simply demonstrated by the use of examples, not all of which may have been entirely apposite, that there can be non-violent unnatural deaths. Dillon LJ then at 628 B turned to the critical question of how such a death can be identified, saying -
"Whether Miss Thomas's death was natural or unnatural must therefore depend on what was the cause of death. At this point, I remind myself of the observation of Lord Salmon in Alphacell Ltd v Woodward [1972] AC 824 at 847, where he said:
`I consider .... that what or who has caused a certain event to occur is essentially a practical question of fact which can be best answered by ordinary common sense rather than by abstract metaphysical theory'".
Miss Thomas was asthmatic, and when the emergency ambulance was called for her it took 33 minutes to arrive. The court did not know the cause of the delay, but there was clear medical evidence that if the delay had not been so great her life would have saved. Dillon LJ considered a number of possible reasons for the delay, including inefficiency of the ambulance crew and slack management, but concluded whatever caused the delay the cause of death was, on Lord Salmon's test, the asthmatic attack. On the facts of that particular case we are prepared to accept, as Simon Brown LJ was prepared to accept at 632 A, that the coroner was entitled to regard the late arrival of the ambulance as not being a significant cause of death, but that does not mean that failure to provide essential treatment can never be regarded as a cause or even the cause of death. For example, if Miss Thomas's attack had been relatively mild and the ambulance had arrived quickly, but its journey to the hospital was extended because the crew stopped for 10 minutes at a public house, with the result that when she arrived at hospital her life could not be saved, then, as it seems to us, a coroner might well say that a cause of her death was the failure of the crew to bring her straight to hospital.
Farquharson LJ agreed with Dillon LJ, and Simon Brown LJ said that he reached the same conclusion by a rather different route, but we are unable to detect any conflict between his judgment and that of the other two members of the court. At 630 E he agreed that "whether or not a death is natural or unnatural depends ultimately upon the view one takes as to the cause of death". At 630 G he raised the important issue of what view the coroner should take of "causes that may well be secondary but are not self-evidently irrelevant", and at 630 H he said that there will be occasions when a coroner can only properly find death to be the result of two causes, either one of which could serve to make it unnatural. Mr Coghlan QC, who appeared for the respondent before us, realistically accepted that on occasions a coroner may have to find that there was more than one cause of death. That possibility was simply not canvassed by Dillon LJ.
So where, as in this case, a patient is in hospital suffering from a condition which if not monitored and treated in a routine way will result in death, and, for whatever reason, the monitoring and treatment is omitted, then, as it seems to us, the coroner must hold an inquest unless he can say that there are no grounds for suspecting that the omission was an effective cause of death. That seems to us to be the conclusion to which one is led by a careful analysis of Thomas. Both counsel before us in the end accepted that approach as correct in law, so all that now remains is to see how the matter was dealt with by the coroner in this case.
4. The attempts to obtain an inquest
On 28th July 1999 Mr Touche wrote to the coroner to seek an inquest. He pointed to the evidence of inadequate monitoring between 11 pm and 1.30 am and suggested that an inquest "would be in the public interest". As I have already pointed out, a coroner cannot hold an inquest just because he believes that to do so might be in the public interest, and on 3rd August 1999 the coroner replied to Mr Touche indicating that he knew of the death but was satisfied that it was "consequent to natural causes", so he had no power to hold an inquest. Mr Touche then consulted his present solicitors who, on 26th August 1999, wrote to the coroner seeking an inquest by reference to section 8(1)(b) and section 8(3)(d) of the 1988 Act. Those references were inappropriate, but the letter did allege that -
"A basic, fundamental failure to record blood pressure readings during and after this routine procedure visiated any opportunity to avoid the catastrophic events which led to Mrs Touche's death."
After a reference to weekend staffing the letter continued -
"The records show a delay of two and one half hours in taking the blood pressure readings which (would) almost certainly have alerted the staff of the impending neurological/vascular accident."
In a follow up letter dated 15th September 1999 the solicitors say -
"The Portland Hospital have already confirmed in writing to our client that a protocol does not exist to reflect the level of monitoring that should be given following a caesarean section. We have expert advice to the fact that every NHS Hospital in the country has a protocol in place for the care of patients in the post-operative phase in order to maintain standards within the hospital and ensure an appropriate level of patient care."
In the same letter the solicitors say at a later stage -
"We consider that hypertension, according to the pathology report, was the contributing factor in the fatal haemorrhage responsible for Laura Touche's death and that an inquest is necessary to explore why the hypertension remained undetected after a caesarean section, due to a failure to monitor blood pressure at all when it is known that hypertension can be expected following a caesarean section and is eminently preventable with aggressive anti-hypertensive therapy.
Maternal death is now very rare in this country as is evidenced by the report on Confidential Enquiries to Maternal Deaths in the United Kingdom."
On 20th September 1999 the coroner replied, indicating his lack of any general discretion and saying he was satisfied that the deceased died consequent to natural causes. He referred to Thomas and continued -
"Even when all the circumstances is taken into account (accepting that the haemorrhage was secondary to hypertension and that there were delays in its discovery), the cause of death was still as above and the death was not an unnatural one. (see Court of Appeal judgment in ex parte Thomas )."
We find that short paragraph difficult to understand. If it was intended to indicate that the law as explained in Thomas excluded the possibility of delay in the discovery and treatment of the hypertension being the cause of death in this case, then, as it seems to us, the coroner must have misunderstood the law. In the next paragraph of the letter the coroner understandably emphasises his limited function, and he concludes by expressing sympathy with Mr Touche. Indeed we must pay tribute to the fact that all of his letters are couched in sympathetic terms.
The coroner's letters of 3rd August and 20th September 1999 are important because they are the decision letters challenged in these proceedings for judicial review. Since they were written more information has become available but, as Mr Coghlan explained, the coroner has not changed his view, so we have been invited to consider this application as though the effective decision was taken on the basis of all of the information now before the court.
On 31st October 1999 the appellant's solicitors obtained a preliminary report from Dr Bogod, an experienced consultant anaesthetist with a particular interest in obstetric anaesthesia. He was very critical of the lack of records relating to the periods during and after surgery. In particular he found a failure to monitor and record vital signs, including blood pressure, in an appropriate environment post-operatively at a time when Mrs Touche was receiving pain relief as astonishing, and described the level of neglect as "starkly apparent".
An application for permission to seek judicial review was then drafted, and on 2nd November 1999 the applicant's solicitors sent the draft and the other relevant documents, including Dr Bogod's report, to the coroner to give him an opportunity to reconsider his decision. He took that opportunity, and on 6th November 1999 wrote to the solicitors saying-
"I approach each and every case with an open mind asking the question whether there is reasonable cause to suspect a deceased person has died a violent or an unnatural death. I would carefully consider whether in the circumstances of each and every case some human faults or failure would render what on the face of it a natural death to an unnatural one, and whether common sense dictate that the death to be an unnatural one."
As Mr Coghlan submits, that suggests that the coroner was adopting an approach which was correct in law, however he concluded -
"I do not believe that there is reasonable cause to suspect that the deceased has died an unnatural death. I remain unpersuaded that it was other than a death by natural causes."
Permission to apply for judicial review was granted by Moses J on 31st January 2000 and the solicitors acting for the coroner then obtained a report from Professor Rubin, whose particular interest is in the medical aspects of pregnancy. In his report of 29th February 2000 he points out that maternal death in the United Kingdom is now very rare, and describes the death of Mrs Touche as extraordinary, because he has experience of countless women who have had blood pressure in her recorded range without having a stroke. His report then discusses how in medical terms her death can be explained, and concludes that the cause of this rare and extraordinary death remains cerebral haemorrhage. He says that he can find no reason to sustain the view that it was unnatural.
In our judgment Professor Rubin's report is of very limited assistance because it does not address the issue central to the applicant's case, namely the relevance of the apparent failure properly to monitor and treat the patient during the immediate post operative phase.
On 7th March 2000 the coroner swore the affidavit which constitutes his evidence in these proceedings. In paragraph 5, dealing with the history, he notes -
"The deceased was returned to the post natal ward in a single room at about 2300 hours. There appears to be no record in respect of the monitoring of blood pressure until approximately 2½ hours later at 0135 hours on 8th February 1999, when the deceased was then complaining of severe headache. Blood pressure was elevated at 190/100."
In paragraph 21 he states -
"I do, as a matter of course, consider whether, in the circumstances of each and every case reported to me, some human fault or failure would render what on the face of it is a natural death, an unnatural one, and whether common sense dictates the death to be an unnatural one, and I did so here."
As Mr Coghlan submits no one can criticise that approach.
The coroner then, in paragraph 22, turned to the facts of this case. He says that he "weighed up on the one hand the pathology evidence of a natural cause of death" and he summarises it. He continues -
"I weighed up on the other hand the seriousness of the matters complained of: the apparent failure to monitor her blood pressure after delivery for about 2½ hours; the question at the very least that a window of opportunity of early detection of hypertension and treatment might therefore have been lost; and the apparent poor record keeping (amongst other complaints highlighted by the applicant)".
In paragraph 23 he considers the administration of Ephedrine ( a point not pursued before us) then, under the heading "Inadequate monitoring/delay in diagnosis" the coroner says -
"I entirely accept that, there are no records of intra operative monitoring and that the post operative monitoring would appear wholly inadequate, not having started for an unacceptably long period following delivery. However, the question I had to address was whether the deceased died an unnatural death applying ordinary common sense, and balancing the factors recited in paragraph 22 above."
In paragraph 24 the coroner concludes -
"I asked myself whether this was a case in which the defects and human faults complained of lifted the case out of the category of natural and into the category unnatural death and, applying my common-sense as a coroner, I concluded that it did not."
As Mr Coghlan emphasises, the legal formulation is not obviously incorrect, although we would prefer to see the coroner asking himself a question along the lines indicated earlier in this judgment, namely whether there ire any grounds for suspecting that the wholly inadequate post operative monitoring and the consequential loss of the opportunity to provide timely treatment was an effective cause of death. If the coroner had approached the matter in that way it seems to us that his conclusion must have been different. It is noteworthy that the coroner does not seek to explain the conclusion he sets out in paragraph 24, and in reality how could he do so? There was available to him no evidence to suggest that even if Mrs Touche had even been properly monitored and treated post operatively she would still have died. We accept that there is a medical explanation for Mrs Touche's death, and that, as Professor Rubin points out, there is no evidence to suggest that anything done at the Portland Hospital caused her hypertension, but in dealing with the statutory test omission can be as important as commission, and that, as it seems to us, is what both Professor Rubin and the coroner failed properly to recognise and to evaluate.
On 15th May 2000 in preparation for the hearing in this court, the applicant's solicitors obtained a preliminary opinion from Dr Williams, who runs the high risk obstetrics service at the Chelsea and Westminster Hospital, and who has a particular interest in pre-eclampsia. Like everyone else, including the coroner, he is critical of the lack of post operative observation, and he asks himself the question "if Laura Touche's blood pressure had been taken during this period (2300 to 0135 on 6.2.99/7.2.99) would the subsequent haemorrhage have been avoided?" At page 77 of the court bundle he concludes that her severe hypertension was responsible for her cerebral haemorrhage, and the hypertension was secondary to pre-eclampsia/eclampsia. He says that if she had not been hypertensive he does not think she would have had a cerebral haemorrhage, and continues -
"When her hypertension was eventually treated she responded with a significant fall in BP within 15 minutes. It is likely that more prompt identification and treatment of her hypertension would have prevented her cerebral haemorrhage."
As Mr Havers QC for the applicant pointed out, if the cerebral haemorrhage had been prevented she would not have died. Thus the report of Dr Williams does seem to provide clear grounds for suspecting that the post operative failure to monitor and treat was an effective cause of death, but as Mr Coghlan made clear the position of the coroner remains unchanged.
On 23rd May 2000 solicitors acting for the Portland Hospital wrote to the applicant's solicitors to provide with what they describe as "a detailed description of the events surrounding the treatment of the deceased at the Portland Hospital". For present purposes, suffice to say that it offers no explanation for the lack of post operative monitoring and the consequential failure to treat. In a letter dated 2nd June 2000 Dr Bogod comments on the letter from the hospital's solicitors. He raises points on which we need not dwell, and points out that Mrs Touche was sent directly back to her room from theatre without spending time in a recovery unit which, he stresses, "is quite unacceptable practice".
5. Conclusion
For the reasons we have set out above it seems to us that if the coroner did adopt an approach which was correct in law, and the documentation does not clearly indicate otherwise, then he reached a conclusion which was irrational in a Wednesbury sense, and which this court should not allow to stand. I would therefore set aside the coroner's decision and direct him to hold an inquest into the death of Laura Touche.
Other matters.
Nothing in this judgment is concerned with what may in due course be the appropriate verdict, so we have not found it necessary to consider "lack of care" or two of the decisions to which we were referred (R v Southwark Coroner ex parte Hicks [1987] 1 WLR 1624 and R v North Humberside Coroner ex parte Jamieson [1995] QB 1). Still less are we concerned with any question of civil liability. Our concern is solely with the propriety of the coroner's decision as to whether or not an inquest should be held.
Before us Mr Havers advanced further submissions, based on Article 2 of the European Convention on Human Rights. Those are not submissions with which we find it necessary to deal in any detail. Suffice to say that if we had not found in his favour on the basis of domestic law his submissions in relation to European Law would not have turned the tide.
Mr Havers also sought to exploit the rarity of the medical sequence of events which led to Mrs Touche's death, and sought to equate that with the Legionnaires Disease to which Dillon LJ referred to in Thomas. Like Mr Coghlan we regard the reference to Legionnaires Disease in the case of Thomas as unfortunate, and to our minds where the cause of death is known and is natural a coroner cannot be required to hold an inquest, nor indeed is he entitled to hold an inquest, simply because the cause of death is rare.

LORD JUSTICE KENNEDY: For the reasons set out in the judgments which have been handed down, this application will be allowed. The coroner's decision will be set aside and he will be directed to hold an inquest into the death of Laura Touche.
We have received, Mr Havers, a couple of corrections for which I am grateful. However often one reads the draft you always find a couple more the next time you read it; I thought we had both read it about twice. On the last page, if anyone has the typed copy, in the paragraph numbered 5, there is plainly a missing "not" in the fourth line between "should" and "allow". I think there is one other on the previous page, page 6, in the indented paragraph which is about three quarters of the way down, in the last line the word "could" should read "would". For both of those I am grateful. There may be others.
MR HAVERS: There is one more, my Lord - a typo at the top of page 3, the second word ----
LORD JUSTICE KENNEDY: Yes thank you. The second word there should be "well" rather than "ill". Thank you very much.
MR COGHLAN: My Lord, may I draw your attention to one point, which arises late in the day because I was not instructed until last night in this matter, having not been in chambers. If your Lordship goes to page 3 and goes to just before the start of the paragraph 4, there is a sentence which reads:
"Both counsel before us in the end accepted that approach as correct in law, so all that now remains is to see how the matter was dealt with ..."
My Lord, may I ask your Lordships to consider striking out the words "Both counsel before us in the end accepted that approach as correct in law ...", so that it simply reads, "That seems to us to be the conclusion to which one is led by a careful analysis of Thomas, so all that now remains is to see how the matter is dealt with by the coroner in this case", for this reason: the sentence but one that precedes that is a sentence which is complex and interesting and which we do not believe was conceded on this side.
LORD JUSTICE KENNEDY: I confess I thought it was, but I am not going to hold you to it if my understanding of the position is wrong.
MR COGHLAN: My Lord, I am very grateful. We looked at the note.
LORD JUSTICE KENNEDY: (Their Lordships confer) It was both our understandings, but, as I say, what does it matter? You are entitled to take a different position.
MR COGHLAN: My Lord, I am very much obliged.
LORD JUSTICE KENNEDY: "That seems to us to be the conclusion to which one is led by a careful analysis of Thomas, so all that now remains ...."
MR HAVERS: The applicant is privately paying. I am seeking an order for his costs in this application.
LORD JUSTICE KENNEDY: Against whom?
MR COGHLAN: May I say as to costs, it has been a little while since I appeared before a coroner. But certainly in the older days costs were not made against a coroner where there was a bona fide defence of a claim for judicial review, particularly where the defence was one which was genuine and in this case based upon, as your Lordships, I think, found, a genuine and an appropriate direction of himself as to the law. There is the old case that used to say that if the coroner has misbehaved himself in some way, then that is different. But otherwise an order for costs is inappropriate.
There are various other reasons I would mention. This was a case where quite a bit of material was to do with European law, which in the end your Lordships held did not help at all; vast quantities of authorities, a junior instructed on this side and counsel on both sides.
Finally, there is this point that the applicant's case -- no criticism of him, but it was an evolving case. Your Lordships will recall that at the start of the case there was a claim in correspondence that there was, to use the words of the Act, "the deceased died a sudden death of which the cause was unknown". That gradually evolved until, I think about two or three weeks before trial, we had a huge mass of evidence from the new doctor, Dr Vickers, which contained over a hundred pages of exhibits and which put the point fairly and squarely on the basis that the treating medical staff failed to monitor the blood pressure and failed to treat as they should have done. So it was an evolving case.
It was really on that latter point that your Lordships have found against the coroner. As he conceded at the hearing, do not send this case away because I will concede again here that, even if that had been the position and I had known that, I would reach the same decision.
For all those reasons, my Lord, I would invite your Lordship to say no order for costs is the appropriate order in this case.
LORD JUSTICE KENNEDY: Is there a power in a case such as this to order costs from the central funds?
MR COGHLAN: I am afraid I do not know the answer to that.
LORD JUSTICE KENNEDY: It applies in relation to magistrates. I am not sure if it applies in relation to coroners. That is why I raise the question.
MR COGHLAN: I personally have no recollection of such order being made, but those instructing me may have something.
LORD JUSTICE KENNEDY: The associate has drawn to my attention the Prosecution of Offences Act. In those circumstances there has to be a criminal offence before one can.
MR JUSTICE MORISON: Could I ask you this. Your client, the coroner, is in fact legally supported, is he not, by a medical defence union?
MR COGHLAN: May I take instructions. (After a pause): No, he is not.
LORD JUSTICE KENNEDY: The solicitors suggested that he might have been. The funding therefore is, what, from the coroner's -- from public funds?
MR COGHLAN: If his local authority are prepared, and we do not know, to pay his costs then that is the answer. But they have not undertaken or guaranteed to do so.
MR JUSTICE MORISON: I am looking at page 47 of our red file, which is a report, the Professor Rubin report, which is said to have been prepared for Hempsons Solicitors. Who paid for that?
MR COGHLAN: (After a pause): That is ultimately going to be paid for by the London Borough of Camden. I think it is right to say that they have agreed to pay that sum, directly or indirectly.
MR JUSTICE MORISON: And they have agreed to pay your side's costs?
MR COGHLAN: I do not believe they have, my Lord. (After a pause): I am told that they have indicated that they will support the coroner financially in the defence of this case. I am sorry.
LORD JUSTICE KENNEDY: We take the view that costs as normal must follow the event. Having said that, and therefore the successful applicant recovers his costs, it seems right, in the context of what we have just heard, also to say that no-one should criticise the coroner for taking what he regarded as a responsible stance and that it would only be right, in our judgment, that the public funds available to those who stand behind him should be used for the purpose of funding him in this litigation. This is not a case where a coroner should, as it were, conceded at the outset that he was wrong and that he should have taken the course that this court now orders him to take. Thank you very much.