CO/2071/2002 
Neutral Citation Number: [2003] EWHC 618 (Admin)
IN THE HIGH COURT OF JUSTICE 
QUEEN'S BENCH DIVISION  
THE ADMINISTRATIVE COURT 
Royal Courts of Justice 
Strand
London WC2 

Tuesday, 11 February 2003
 B E F O R E:

MR JUSTICE MOSES 

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THE QUEEN ON THE APPLICATION OF CHRISTINE DAVIES
(CLAIMANT)

-v- 

HM DEPUTY CORONER FOR BIRMINGHAM
(DEFENDANT)
(1) HM PRISON SERVICE
 
(2) PRISON OFFICERS' ASSOCIATION 
(INTERESTED PARTIES) 
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Computer-Aided Transcript of the Stenograph Notes of 
Smith Bernal Wordwave Limited
190 Fleet Street  London EC4A 2AG
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MR TIM OWEN QC AND MISS PAULA SPARKS (HEARING) MISS OLIVIA HOLDSWORTH(JUDGMENT) (instructed by Jonas Roy Bloom, Birmingham, B4 6QD) appeared on behalf of the CLAIMANT
MR RICHARD BARRACLOUGH (instructed by Birmingham Coroner's Court, Birmingham, B4 6NE) appeared on behalf of the DEFENDANT 
Tuesday, 11 February 2003
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J U D G M E N T 
1.	MR JUSTICE MOSES:  This is a tragic case.  On 5 March 2001 Darren Davies died whilst in custody at HM Prison Winston Green.  He was only 23.  He died from the effects of dehydration following, but not necessarily caused by, symptoms of withdrawal from heroin.  After an inquest held over a period of five days the jury returned a verdict of accidental death on 1 February 2002.  
2.	The claimant is the deceased's mother.  She contends that the coroner failed properly to direct the jury as to the meaning of neglect, failed to permit evidence from an independent expert, Dr Ralli, relating to his views as to the quality of care afforded the prisoner, and failed adequately to leave to the jury the issue as to whether the system for his care on and after admission was defective.  
The Facts 
3.	There appears to have been unanimity amongst the doctors as to the cause of death.  Dr Tapp said that it was due to dehydration consistent with someone suffering from significant diarrhoea and vomiting.  The cause might never be ascertained.  It was unlikely to be drug withdrawal.  He suffered from the symptoms of acute enteritis.  Dr Ralli commented that the cramps which the deceased suffered from in his upper limbs, and particularly in his hands, were unusual.  Dr Khan described the symptoms as being most unusual, particularly those of very severe dehydration.  Dr Acland concurred in the unusual nature of the cause of death and took the view that he had died from the complications of dehydration.  
4.	The deceased was seen on his admission to the prison on 1 March 2001 by a Dr Rahman at about 7pm.  Notes were made in a health screen record that, as his mother confirmed, he had taken heroin the day before.  The deceased was complaining of aches and pains.  He was prescribed, by Dr Rahman, detoxification drug treatment, to be taken over a period of four days.  The next day, Friday 2 March 2001, the deceased attended for his second dose, but his card recording the treatment prescribed to him had been placed in the tray designated for a wing different from that on which he had been placed.  Accordingly, the drug could not be prescribed and he did not attend again once the card had been sent to the correct wing, which was C wing.  By mid-morning the deceased had been placed on a different wing, B wing.  That wing held a sick parade on a different day, so he never received a further detoxification treatment dose.  Whilst in B wing, he rarely left his cell.  He shared that cell with a fellow inmate, who gave evidence, Mr Collins.  
5.	The deceased's sister gave evidence.  She had rung the prison to ask whether he had the medication he was to receive.  She was told by the nurse who answered the telephone call that she was not in any position to check whether he had received that dose or not.  
6.	His fellow inmate, Mr Collins, described his worsening symptoms.  He could not take water.  When he did try to do so he was sick straight away and he was suffering from pain.  I have been furnished with all the transcripts of all the evidence as well as the summing-up.  Mr Collins' evidence described the deceased calling for assistance by pressing the buzzer in the cell on Saturday evening.  He could not remember whether it was twice or once on that Saturday night.  The buzzer was rung at 9.15 on the Saturday evening.  The deceased was advised by a prison officer to see a nurse the next day and, apparently, according to the fellow inmate Mr Collins, the prison officer who visited that evening said "you got on your boat, you ride it", meaning that it was his own fault for having taken drugs earlier.  
7.	On the next day, Sunday 4 March 2001, Mr Collins said that the deceased was worse.  He did not get out of bed.  He did not get out of the cell for exercise.  He complained of a bad chest.  His fingers were clamped up.  He could not move them.  He was worse on Sunday evening.  He was still vomiting, was too weak to go to the lavatory and had spasms in his elbows and fingers.  The buzzer was pressed.  A prison officer called and he was advised to take paracetamol.  The nurse, who also attended, advised the inmate to make sure that the deceased went for treatment on the Monday morning.  The nurse who attended was a Nurse Spencer, who, I was told, was not a general nurse but had particular skills in the mental health field.  She manipulated the deceased's joints.  On returning to the health centre, she checked his record.  She discovered that the health centre was full.  
8.	The next morning, the morning he died, the buzzer was pressed at 6.15.  The deceased had fallen off the bed.  He was lifted onto the bed by two prison officers and Nurse Spencer.  The nurse told him that a doctor would see him.  According to Mr Collins, he told the nurse that the deceased had been sick.  In cross-examination he said he had cleaned up the vomit.  Prison Officer Biddle gave evidence, saying he had visited the cell both on the night before, the Sunday, and the Monday morning.  The night before, the deceased wrists were in an unnatural position and rigid, although on the Monday morning they were more flexible.  The deceased was told he was going to be referred to a doctor that Monday morning.  
9.	Less than an hour later, at 7.10 in the morning, the cell buzzer was pressed again.  By that time the deceased was unconscious.  He was not breathing.  Steps were taken to try to revive him.  An ambulance was called, but, despite the attempts of a paramedic to resuscitate the deceased, he died.  
10.	Prison Officer Fitzgerald gave evidence, recalling two calls on Sunday night.  The deceased was advised to see the doctor on the first occasion.  One and a half hours later the deceased was still in pain.  The nurse was called.  His arms were hurting and Prison Officer Fitzgerald remembers the cell mate, Mr Collins, saying that the deceased had been sick.  The deceased's arms were in a cramped position.  On the Monday he had fallen on the floor and Prison Officer Fitzgerald described him being lifted onto a bed.  She ascribed the symptoms to drugs.  
11.	Nurse Spencer gave important evidence describing attending on Sunday night, manipulating the deceased, giving him paracetamol and advising him to attend the health care centre the next day.  She had seen those withdrawing from drugs suffering from spasms on previous occasions.  The following morning she saw no evidence of dehydration.  His lips were not sticking together.  She did not find the symptoms particularly unusual.  She did not think it odd that the deceased had failed to follow up the prescription he had been given for the detoxification programme.  When she saw him on the Monday morning he was stretched out, but his hands were more supple.  He was coherent in talking, and complaining of suffering from discomfort in the joints.  She saw no evidence of diarrhoea or vomiting and smelt none of the effects of those symptoms.  She ascribed the symptoms to drug withdrawal.  She said she had no concern, other than wishing him to see a doctor that morning.  If she had thought that it was necessary to call out a doctor, she could have done so easily.  She attributed all the deceased's symptoms to withdrawal.  
12.	Dr Ralli was a prison doctor at another prison who furnished an independent report.  During the course of that report, he made comments on clinical issues: 
"(1)  After Mr Davies reception assessment a treatment plan was established, the onus was placed on him to seek his treatments and further help if required.
"(2)  No one checked to see why he did not attend for treatment or to attend reporting sick or to collect his meals.
"(3)  Practices are in place for those considered to be at risk if they don't receive their treatment (diabetics, those on heart medicines) to be followed up; but this doesn't seem to extend to drug users.  Given all the recognised risks amongst drug users on coming into prison especially from self-harm, this needs to be reviewed.
"(4)  Follow up and taking the treatment prescribed may have prevented his deterioration.  
"(5)  Mr Davies presentation on the Sunday night was unusual the nurse did not elicit all the information about the vomiting, diarrhoea and no food or fluid intake nor that he had not taken any of his prescribed medicine.
"(6)  She should have discussed the case with the duty doctor.  
"(7)  She should have been able to move him to an area for closer health care supervision.  HMP Birmingham does not have such a resource, as the inpatients are not monitored by health care staff through the night.  
"(8)  Mr Davies collapse in the early hours is also very unusual again there should have been discussion with the duty doctor and arrangements for closer monitoring."
The last three points were excluded, by the coroner's ruling, from the jury, but it is to be noted that the fifth point, relating to the unusual nature of the presentation and the fact that the nurse did not elicit all the information, was before the jury.  Further, in giving evidence, Nurse Spencer commented that, if there was a history of vomiting profusely, you would want to examine this person, perhaps do some blood tests. Dr Ralli himself commented in oral evidence on the desirability of treatment, having regard to the unusual nature of the presentation.  
13.	There was further evidence from Mr Pascoe and Mr Price.  Mr Pascoe was a governor, giving independent evidence.  He gave evidence as to the lack of machinery for follow-up after an initial assessment, although he spoke of the speed at which people arrived at the scene.  He described the nurse's decision as professional medical judgment.  The assistant governor at Birmingham, Mr Price, described the detoxification programme and the quality of the nurses.  He said that a doctor was on call 24 hours a day, and the hospital was only two minutes away.  The coroner then summed-up the case.  
Issues 
14.	The claimant contends that the coroner misdirected the jury.  Firstly, he wrongly emphasised the rarity of a verdict that neglect had contributed to the cause of death.  Secondly, he failed to explain that there were circumstances in which Nurse Spencer's failure to seek assistance could amount to neglect, notwithstanding her decision, as a matter of judgment, that such assistance was unnecessary.  Thirdly, he failed to leave the issue of a failure in the system of care for a prisoner requiring medication for drug withdrawal.  Fourthly, he erred in preventing the full deployment of all Dr Ralli's views before the jury.  
Principles  
15.	I turn to the principles relevant to the determination of the issues.  Before the decision of the Court of Appeal in R(Amin and Middleton) v Home Secretary [2002] 3WLR Page 505 and before the Human Rights Act 1998 came into force, the meaning of neglect was explained by Sir Thomas Bingham MR, as he then was, in R v HM Coroner for North Humberside and Scunthorpe, ex parte Jamieson [1994] QB, page 1.  At page 24 the Master of the Rolls set out certain conclusions.  He emphasised the nature of the fact-finding enquiry to be conducted by a coroner.  At (3) he said: 
"It is not the function of a coroner or his jury to determine, or appear to determine, any question of criminal or civil liability, to apportion guilt or attribute blame.  This principle is expressed in rule 42 of the Rules of 1984.  The rule does, however, treat criminal and civil liability differently: whereas a verdict must not be framed so as to appear to determine any question of criminal liability on the part of a named person, thereby legitimating a verdict of unlawful killing provided no one is named, the prohibition on returning a verdict so as to appear to determine any question of civil liability is unqualified, applying whether anyone is named or not."
At Principle (9) he continued: 
"Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide or procure basic medical attention or shelter or warmth for someone in a dependent position (because of youth, age, illness or incarceration) who cannot provide it for himself.  Failure to provide medical attention for a dependent person whose physical condition is such as to show that he obviously needs it may amount to neglect.  So it may be if it is the dependent person's mental condition which obviously calls for medical attention (as it would, for example, if a mental nurse observed that a patient had a propensity to swallow razor blades and failed to report this propensity to a doctor, in a case where the patient had no intention to cause himself injury, but did thereafter swallow razor blades with fatal results).  In both cases the crucial consideration will be what the dependent person's condition, whether physical or mental, appeared to be."
Principle (12), page 26, was described by the Master of the Rolls as: 
"Neither neglect nor self-neglect should ever form any part of any verdict unless a clear and direct causal connection is established between the conduct so described and the cause of death."
16.	In Amin and Middleton (qv supra) the Court of Appeal considered the impact of Article 2 of the European Convention on Human Rights and considered the impact of the decision of the European Court of Human Rights in Osman v United Kingdom [1998] 29 EHRR 245, at 305 to 306.  Without a duty to investigate, the substantive right conferred by Article 2 would or might in some cases be rendered ineffective.  Thus the duty to investigate was described by the court as 'adjectival', see paragraph 32.  At paragraph 62 the court said: 
"What is required (by way of investigation) will vary with the circumstances.  A credible accusation of murder or manslaughter by state agents will call for an investigation of the utmost rigour, conducted independently for all to see.  An allegation of negligence leading to death in custody, though grave enough in all conscience, bears a different quality from a case where it is said the state has laid on lethal hands.  The procedural obligation promotes interlocking aims: to minimise the risk of future like deaths; to give the beginnings of justice to the bereaved; to assuage the anxieties of the public.  The means of their fulfilment cannot be reduced to a catechism of rules.  What is required is a flexible approach responsive to the dictates of the facts case by case."
Turning to the case of Middleton, the court considered the ruling of Stanley Burnton J in that case, in which he granted a declaration that the restrictions on the verdict at the inquest were inadequate to meet the procedural obligations in Article 2 of the European Convention on Human Rights.  The Court of Appeal considered the decision of Jamieson in these terms at paragraph 87: 
"A verdict of neglect can perform different functions.  In particular, in the present context, it can identify a failure in the system adopted by the Prison Service to reduce the incidence of suicide by inmates.  Alternatively, it may do no more than identify a failure of an individual prison officer to perform his duties properly.  We offer two illustrations, which demonstrate the distinction we have in mind.  On the one hand, the system adopted by a prison may be unsatisfactory in that it allows a prisoner who is a known suicide risk to occupy a cell by himself or does not require that prisoner to be kept under observation.  On the other hand, the system may be perfectly satisfactory but the prison officer responsible for keeping observation may fall asleep on duty.  
"For the purpose of vindicating the right protected by article 2 it is more important to identify defects in the system than individual acts of negligence.  The identification of defects in the system can result in it being changed so that suicides in the future are avoided.  A finding of individual negligence is unlikely to lead to that result.  If the facts have been investigated at the inquest the evidence given for this purpose should usually enable the relatives to initiate civil proceedings against those responsible without the verdict identifying individuals by name.  The shortcomings of civil proceedings in meeting the requirements of article 2 do not in general prevent actions in the domestic courts for damages from providing an effective remedy in cases of alleged unlawful conduct or negligence by public authorities.  
"In contrast with the position where there is individual negligence, not to allow a jury to return a verdict of neglect in relation to a defect in the system could detract substantially from the salutary effect of the verdict.  A finding of neglect can bring home to the relevant authority the need for action to be taken to change the system, and thus contribute to the avoidance of suicides in the future.  The inability to bring in a verdict of neglect (without identifying any individual as being involved) in our judgment significantly detracts, in some cases, from the capacity of the investigation to meet the obligations arising under article 2."
Then, towards the end of the judgment, the court said at paragraph 91, page 541: 
"In a situation where a coroner knows that it is the inquest which is in practice the way the state is fulfilling the adjectival obligation under article 2, it is for the coroner to construe the Rules in the manner required by section 6(2)(b).  Rule 42 can and should, contrary to R v Coroner for North Humberside and Scunthorpe, Ex p Jamieson [1995] QB 1, when necessary be construed (in relation to both criminal and civil proceedings) only as preventing an individual being named, with the result that a finding of system neglect of the type we have indicated will not contravene that rule.  If the coroner is acting in accordance with the rule for this purpose he will not be offending in this respect section 6(1).  
"For a coroner to take into account today the effect of the Human Rights Act 1998 on the interpretation of the Rules is not to overrule Jamieson's case by the back door.  In general the decision continues to apply to inquests, but when it is necessary so as to vindicate article 2 to give in effect a verdict of neglect, it is permissible to do so.  The requirements are in fact specific to the particular inquest being conducted and will only apply where in the judgment of the coroner a finding of the jury on neglect could serve to reduce the risk of repetition of the circumstances giving rise to the death being inquired into at the inquest."
17.	It is possible to derive from Amin and Middleton the proposition that a verdict of system neglect may be appropriate in order to identify defects in the system and prevent their recurrence.  Such an identification of the defects in the system is to be contrasted with an identification of negligent acts by an individual.  
18.	The decision in Amin is subject to criticism in the current edition of Jervis on the Office and Duties of Coroners [2002].  Any discussion has added piquancy by the fact that the foreword was written by Lord Woolf CJ who presided in the Court of Appeal in the decision of Amin.  However, the decision in Amin is binding upon me.  For the purposes of this decision, it is unnecessary to consider the extent to which the Court of Appeal was laying down a different test for a conclusion that there were defects in the system amounting to neglect than would have been applied before concluding that the acts or omissions of an individual amounted to neglect.  It seems clear that the Court of Appeal was not intending to qualify the rigours of the Jamieson test in relation to the acts or omissions of an individual.  I note the contrast emphasised at paragraph 89.  
19.	However, for the purposes of the instant case, it is important to emphasise that a gross failure, in accordance with the Jamieson test, may be found even where an individual has purported to make a clinical decision or diagnosis.  Gross failures are not limited to those cases where an individual has failed to take any action at all, (see for example the decision of the Divisional Court in Cleo Scott v HM Coroner for Inner West London [2001] EWHC Admin 105).  Keene LJ in that case said: 
"There have been a number of cases where there had been medical attention but where neglect remained a possible element in a verdict ... Omissions on the part of medical practitioners are capable of forming part of the total picture which amounts to neglect."
20.	In R(Nicholls) v Coroner for City of Liverpool [2001] EWHC Admin 922 the Divisional Court was concerned with the alleged failure of a police forensic medical examiner properly to recognise the fact that the deceased had swallowed drugs, believed to be heroin.  It is plain that the Divisional Court accepted that his failure could amount to neglect.  At paragraph 52 Sullivan J, with whom Rose LJ, the Vice President agreed, said:
"Notwithstanding Mr Burnett's submission that neglect and negligence are two different 'animals', there is, in reality, no precise dividing line between 'a gross failure to provide ... basic medical attention' and a 'failure to provide ...  medical attention'.  The difference is bound to be one of degree, highly dependent on the facts of the particular case."
The coroner's summing-up 
21.	Before turning to specific criticisms advanced, I should emphasise my sympathy with the deputy coroner in the instant case.  We judges have the assistance of enormous help and guidance from the Judicial Studies Board.  Astonishingly, despite previous judicial comment, no such assistance appears to be available to coroners.  They have no opportunity to study model directions and no opportunity to hear others direct juries.  The need for standard directions was emphasised some time ago by Lord Woolf in R v Inner South London Coroner, ex parte Douglas Williams [1999] 1 All England Reports at page 344.  
22.	The first criticism related to an assertion that the deputy coroner placed undue emphasis on the rarity of a verdict of neglect.  At page 69 of the transcript of his summing-up he said: 
"But you must understand that it is nothing at all to do with negligence.  It is very unusual and will only arise in a very, very, small percentage of cases, but in view of the circumstances of this case, it was appropriate that you are given the option."
At page 76E he emphasised again the rarity of the verdict, quoting the textbook by Mr Dorries on inquests:
"'Such cases will be very few and far between.'"  
The coroner probably meant no more than to emphasise the contrast with negligence and the need to identify gross failure, which, he emphasised on more than one occasion, had an extremely "narrow meaning", as he called it.  But, I should say that, to the extent the deputy coroner did comment upon the rarity of such a verdict, he was, in my view, wrong.  To comment on the rarity did not assist in defining neglect to the jury.  
23.	The source of such a comment as to the rarity of the verdict stems, to my mind, from his misunderstanding of a decision of Mann J, as he then was, in R v Portsmouth Coroner, Ex parte Anderson [1987] 1 WLR at page 1640.  At page 1647 Mann J cited a passage from R v Southwark Coroner, Ex parte Hicks [1987] 1 WLR 1624 from the judgment of Croom-Johnson LJ.  Croom-Johnson LJ emphasised the illogicality of a verdict of accident aggravated by lack of care.  Croom-Johnson LJ pointed out that it was perfectly legitimate to regard a lack of care as contributing to a cause of death either before or after the actual cause, as I have said.  But he pointed out that an accident aggravated by lack of care was illogical.  As he said: 
"The lack of care in supervising the bathing party may have been the cause of the accident, but it did not aggravate anything at all."  
In ex parte Anderson Mann J observed that the absence of rehydration equipment did not aggravate the cause of death.  He said: 
"The presence of the equipment might have ameliorated the condition which in fact led to death but its absence did not aggravate.  In my judgment, the coroner was correct in not raising the question of aggravation by lack of care.  I add that I do not decide that aggravation by lack of care is never appropriate in a case of accidental death but, like Croom-Johnson LJ I think that such a case is unlikely in the extreme: see ante, p1634G." 
Mann J was thus reiterating Croom-Johnson LJ's exposition of the logically fallacious concept of neglect aggravating an accidental death.  Neglect may cause or contribute to a cause of death, natural or unnatural, or indeed suicide, but the remarks as to the rarity of such a verdict should be confined to "accident aggravated by neglect" as was emphasised by Brooke LJ in R v Lincoln Coroner, ex parte Hay [2000] Lloyd's Law Reports, page 264 at page 277.  As I have said, I see no merit in commenting upon its rarity in seeking to define neglect in order to assist the jury.  
24.	Rare or not, the reference to the unusual nature of such a verdict is not, in my judgment, of itself a ground for disturbing the verdict of the jury in the instant case.  The error of the deputy coroner was not, in its context, reading the summing-up as a whole, such a misdirection as to vitiate the jury's conclusion, even if it was not likely to assist the jury in understanding the concept of neglect.  
25.	The other two defects in the summing-up are, to my mind, more serious.  Firstly, the deputy coroner failed to make clear to the jury that Nurse Spencer's failure to seek assistance was at least capable of constituting neglect, even though she exercised her judgment that it was unnecessary to call for any assistance.  The summing-up never made it clear to the jury whether an exercise of her judgment, could or could not constitute neglect.  At the outset of the summing-up, at page 5B, he said: 
"You have to establish the facts.  For example, did someone make a decision?  Yes or no.  It is not your province to determine whether that decision was right or wrong."  
26.	At page 70E in the summing-up, he said of the meaning of neglect: 
"It is a very, very, narrow definition indeed.  First of all there has got to be a gross failure which really means a total and complete failure; to provide adequate nourishment, liquid, et cetera, so it really means doing absolutely nothing.  It doesn't mean doing your incompetent best, if that be the situation.  It means doing absolutely nothing.  It's far more than an error of judgment, if an error of judgment there has been.  There's got to be a total and complete failure."
Pausing there, that passage suggests that, since Nurse Spencer did something, namely attended and formed a conclusion, it was not open to the jury to find neglect.  But, by way of contrast, shortly afterwards the coroner appears to say the opposite.  He told the jury: 
"An error of judgment by an individual, being an individual qualified to make that judgment, as to the appropriate medical attention needed by Mr Davies would not amount to a gross failure unless it can be said that their plan was plainly wrong and they would not have allowed the plan ... followed the plan if they were to stop and think about it in the cold light of day."
Whatever one's criticism as to the clarity of that direction, it does at least appear that at that point the coroner was directing the jury that it was open to them to find neglect, notwithstanding the exercise of judgment.  
27.	Later, he appears to revert to the view and direction that the jury were not concerned with whether the assessment was right or wrong.  At page 71D the coroner said: 
"So Nurse Spencer made her clinical assessment.  Whether or not that assessment was right or wrong, as we've said more than once, we're not concerned with.  She made that assessment."
28.	In my judgment, reading the directions as a whole, it cannot have been made clear to the jury, as it ought to have been, that it was open to them to find neglect, notwithstanding the apparent exercise of judgment by the nurse that it was unnecessary to seek assistance for the deceased.  I am far from saying that a verdict of neglect would have been correct.  That would depend in part upon the somewhat confused evidence as to how much Nurse Spencer had been told, but, in the light, of the decision of Keene LJ in Cleo Scott, amongst others, her failure to seek assistance was capable of constituting neglect, even though she exercised a clinical judgment as to whether such assistance was necessary.  This was not made clear to the jury.  
29.	Further, the coroner failed to leave to the jury any issue as to defects in the system.  I should emphasise that he did not have the benefit of the decision of the Court of Appeal in Amin and Middleton, decided very shortly afterwards, but there was an issue as to whether the system for following up inmates on admission who were withdrawing from drugs and required medication was defective.  Indeed, Dr Ralli commented upon defects in the system and his comments had been taken up by the witnesses, Messrs Pascoe and Pratt.  Those criticisms led, as I will note later, to a letter from the coroner, yet identification of any defects in the system and whether that constituted a neglect in the system was never laid before the jury.  
30.	The final criticism relates to the failure to place the evidence of Dr Ralli in full before the jury.  It was not left to the jury on the basis that it was unnecessary in the light of Nurse Spencer's decision.  It was, so the coroner thought, irrelevant to consider what might have happened, had she reached a different view as to the deceased's condition.  
31.	The doctor's evidence may be regarded as constituting implicit criticism, especially in the light of his emphasis on the unusual situation, but I do not think that that ruling of the coroner led to any defect in the conduct of the inquest.  Dr Ralli fell short of saying what a reasonable nurse would have done in the exercise of reasonable care.  I contrast that situation with the situation in Nicholls, where the doctor had stated that the death was entirely preventable by steps exercised by any doctor acting to a reasonable standard.  No such evidence was contained in the report of Dr Ralli.  In those circumstances, I decline to conclude that the jury was wrongly deprived of the opportunity to consider the final three points in Dr Ralli's criticisms.  
32.	I conclude that the directions were deficient in failing to explain to the jury the circumstances in which it was open to them to find that Nurse Spencer's conduct amounted to neglect, and in failing to leave it open to them to find that there were system defects which constituted neglect.  The question then arises as to what remedy I should provide.  I ought not to quash the verdict or to order a fresh inquest unless it is necessary and desirable in the interests of justice to do so, see Lord Woolf MR, as he was then, in R v Inner South Coroner's Court, ex parte Douglas Williams QB Supra at page 347.  
33.	I acknowledge how distressing, anxious and important a matter this is for the relatives.  But in this case a very full enquiry with an abundance of evidence as to the system, as well as to what occurred, took place.  It led the coroner to write to the governor of HM Prison Winston Green in a letter dated 7 February 2002.  He spoke of his concern as to the lack of involvement in the nursing and drug team involved in the rehabilitation.  He recorded that a new procedure had been set in place, but continued: 
"I am still concerned however that a prisoner who may be suffering from withdrawal symptoms may slip through the net because the prison officer or nurse at the Treatment Hatch may not recognise the signs or symptoms.  Therefore, the sooner a new prisoner can be seen, assessed and taken under the wing of the Drugs Team the better and although I appreciate that there are staffing and costs implications, I wonder whether a procedure could be introduced to ensure that a prisoner who arrives on a Thursday or Friday is dealt with in the same way as a prisoner who arrives earlier in the week."
Thus, recommendations relevant to the tragic death of the deceased were made.  It is difficult, therefore, to see what there is further to be gained from another inquest, when evidence was given so fully on the last occasion and recommendations as to improvements in the system were made.  In those circumstances, I decline to quash the verdict or order a fresh inquest.  I shall hear argument as to whether any other relief is desirable or necessary.
34.	MISS HOLDSWORTH:  My Lord, I am not instructed to argue for any further relief.
35.	MR JUSTICE MOSES:  Somebody could draft out a declaration, but I really see absolutely no point. 
36.	MISS HOLDSWORTH:  No, my Lord.  I am not instructed to seek anything like that.
37.	MR JUSTICE MOSES:  Thank you very much.
38.	MISS HOLDSWORTH:  In respect of costs, however, the claimant does have the benefit of a full legal aid order and it would be my application for an assessment of costs and a legal aid certificate.
39.	MR JUSTICE MOSES:  Do you not need to ask for costs as well?  Should you not ask for costs?
40.	MISS HOLDSWORTH:  It is not my application to ask for costs, my Lord.
41.	MR JUSTICE MOSES:  Very well.  Is there anything you want to say?
42.	MR BARRACLOUGH:  I am not asked to apply for any costs either.
43.	MR JUSTICE MOSES:  Thank you both very much.