Nguyen v HM Assistant Coroner for Inner West London

Factual and Procedural Background

This opinion concerns an application under section 13 of the Coroners Act 1988 for the quashing of the inquisition into the death of an infant, referred to herein as the deceased, whose death was originally investigated through an inquest held in November 2017 before an Assistant Coroner in the London Inner West Westminster coroner area.

The deceased was admitted to a hospital emergency department suffering from fever and deteriorating condition, treated for sepsis, and subsequently transferred to a high dependency unit where he suffered cardiac arrest and died. The medical cause of death was found to be lymphocytic myocarditis and disseminated enterovirus infection, a rare and serious condition.

The claimant, the deceased's parent, challenged the inquisition on three grounds: (1) the Assistant Coroner's refusal to hear evidence from an expert instructed by the claimant and failure to share that expert's report with the Assistant Coroner’s expert; (2) the existence of new evidence justifying reopening the inquisition; and (3) alleged predetermination of key issues by the Assistant Coroner.

The case involved extensive factual and expert evidence concerning the clinical management of the deceased during his hospital admission, including evaluations of blood gas tests, clinical observations, escalation of care, and the timing and appropriateness of interventions such as fluid resuscitation, intubation, and transfer to intensive care.

Investigations included a Serious Untoward Incident (SUI) report by the Trust, which identified multiple failings in the standard of care, and expert reports commissioned by the coroner and the claimant’s solicitors. The Trust later admitted liability in civil proceedings relating to the death.

The original inquest heard evidence from multiple clinicians and experts over three days. The Assistant Coroner delivered a narrative verdict of death by natural causes and expressed critical views on some expert reports during the hearing.

Legal Issues Presented

1. Whether the Assistant Coroner erred in refusing to call the claimant’s expert witness and in failing to provide that expert’s report to the Assistant Coroner’s expert, thereby rendering the inquest procedurally unfair or insufficient.
2. Whether new evidence has emerged that justifies reopening the inquest under section 13 of the Coroners Act 1988.
3. Whether the Assistant Coroner demonstrated apparent bias or predetermination in the conduct of the inquest.

Arguments of the Parties

Appellant's Arguments

• The Assistant Coroner’s refusal to call the claimant’s expert was a Wednesbury unreasonable decision, particularly as the expert was qualified to address standard of care issues that the Assistant Coroner’s expert was not.
• The failure to share the claimant’s expert report with the Assistant Coroner’s expert deprived the inquest of important evidence relevant to causation and standard of care.
• New expert evidence, including reports from additional consultants, supports a different view on the adequacy of care and causation, warranting a fresh inquest.
• The Assistant Coroner’s questioning and conduct suggested a closed mind and bias favoring the treating clinicians, undermining the fairness of the inquest.

Respondent's Arguments

• The Assistant Coroner’s decision not to call the claimant’s expert was a legitimate case management decision within her broad discretion and not Wednesbury unreasonable.
• The Assistant Coroner directed that the claimant’s expert report be provided to the Assistant Coroner’s expert, fulfilling procedural fairness, although this was not effected due to administrative error.
• The inquest heard extensive evidence over three days, including from multiple experts and clinicians, satisfying the duty to investigate fully and fairly.
• The Assistant Coroner’s questioning, while robust, did not amount to apparent bias or predetermination.
• The claimant’s expert did not provide a view on causation, limiting the relevance of his evidence to the inquest.
• New evidence was not available at the time of the original inquest but the Assistant Coroner was neutral on whether it justified reopening the inquest.

Table of Precedents Cited

Precedent	Rule or Principle Cited For	Application by the Court
R v HM Coroner for North Humberside and Scunthorpe, ex parte Jamieson [1995] QB 1	Definition of the scope of coronial inquests, meaning of "neglect" and coroner's duty to investigate fully and fairly.	Guided the court’s understanding of the coroner’s investigatory role and the meaning of neglect as a gross failure causally linked to death.
Mack v HM Coroner for Birmingham [2011] EWCA Civ 712	Coroner’s discretion to call expert witnesses is reviewable on Wednesbury principles.	Supported that the Assistant Coroner’s refusal to call the claimant’s expert was within discretion and not unreasonable.
R (Ahmed) v South and East Cumbria Coroner [2009] EWHC 1653 (Admin)	Coroner’s duty to call sufficient witnesses to undertake a proper inquiry.	Reinforced the importance of adequate evidence but did not mandate calling all experts.
Re Fletcher [1992] 156 J.P.N. 460	Test for admission of new evidence at inquests.	Applied to assess whether new expert evidence justified reopening the inquest.
R (Sutovic) v HM Coroner for North London [2006] EWHC 1095	Considerations for admitting new evidence and ordering fresh inquests.	Used to evaluate the significance of new evidence and interests of justice.
Howlett v Devon Coroner [2006] EWHC 2570 (Admin)	Factors relevant to the exercise of discretion under section 13 of the Coroners Act 1988.	Guided the holistic assessment of whether a fresh inquest should be ordered.
McDonnell v HM Assistant Coroner for West London [2016] EWHC 3078 (Admin)	Limits on ordering fresh inquests based on possibility of different verdict.	Informed the court’s caution about reopening inquests absent strong justification.
R (Pounder) v HM Deputy Coroner for the North and South Districts of Durham and Darlington [2010] EWHC 328 (Admin)	Test for apparent bias in coronial proceedings.	Applied to assess whether the Assistant Coroner’s conduct gave rise to real possibility of bias.
Arab Monetary Fund v Hashim (1993) 6 Admin LR 348	Judicial conduct and expression of views during proceedings.	Clarified that expression of scepticism is not bias unless closed mind is shown.

Court's Reasoning and Analysis

The Court carefully reviewed the factual narrative, expert evidence, and procedural history. It acknowledged the complexity of the medical issues and the tragic circumstances.

On Ground 1, the Court recognized the Assistant Coroner’s wide discretion to manage evidence and witnesses, which is subject to Wednesbury unreasonableness review. The Court found that the Assistant Coroner’s decision not to call the claimant’s expert was a nuanced case management choice, made on the basis that the expert’s evidence largely duplicated that of the SUI panel and that the expert had not addressed causation. The direction to provide the claimant’s expert report to the Assistant Coroner’s expert was appropriate, and the failure to do so was an administrative error that did not invalidate the decision. The Court concluded there was no Wednesbury error.

Regarding Ground 2, the Court applied the test for new evidence under Re Fletcher and related authorities. It found that new expert reports were credible, relevant, and might materially affect the verdict, potentially leading to a finding of neglect rather than natural causes. The Court balanced factors for and against reopening, including the thoroughness of the original inquest and the availability of experts at that time, but ultimately concluded that in the interests of justice a fresh inquest was desirable to consider the new evidence fully.

On Ground 3, the Court examined the Assistant Coroner’s questioning style and conduct. While acknowledging that some questioning was assertive and that the Assistant Coroner expressed provisional views during the hearing, the Court found no evidence of apparent bias or closed mind. The Assistant Coroner’s conduct was robust but remained within the bounds of judicial propriety.

Holding and Implications

The Court’s final decision was as follows:

The inquisition into the death of the deceased held in November 2017 is quashed.

A fresh investigation and inquest shall be held by a Senior Coroner, Area Coroner, or Assistant Coroner with no prior involvement in the case.

There is no order as to costs.

The direct effect of this decision is to ensure a new inquest will be conducted to consider new expert evidence and address concerns about the original inquiry’s completeness. The decision does not establish new legal precedent but reinforces established principles governing coronial discretion, new evidence, and procedural fairness in inquests.