Articles Professional Discipline 27th Feb 2020

The importance of giving reasons

R. (on the application of Lewis) v Senior Coroner for North West Kent [2020] 2 WLUK 180

This recent judicial review highlights the importance of a coroner providing reasons when a particular conclusion is not left to the jury.

The deceased suffered from paranoid schizophrenia and was placed under psychiatric care. From 2016 she began to decline physically, suffering from hair loss, diarrhoea, and poor eyesight. In February 2017 she was admitted to an external hospital for treatment but she subsequently returned to the psychiatric unit. In July she was found partially conscious, undernourished, and with poor oral hygiene and bed sores. Just under two weeks later she died despite treatment. The cause of death was recorded as malabsorption as a result of bariatric surgery she had undergone years earlier. At the inquest a doctor gave evidence that she had faded away before staff’s eyes and questioned the aftercare she received following her return to the psychiatric unit. The family criticised the unit’s failure to follow its policy on hydration and nutrition, the failure to keep adequate records of the deceased’s weight loss, and the failure to seek timely advice from a dietitian. The family argued that neglect should properly be left to the jury. However, when the coroner summed up the case he made no reference to neglect. The family raised this omission and the coroner essentially confirmed this was deliberate. In doing so he made brief reference to Jamieson and Galbraith. The deceased’s sister sought to challenge this decision. She submitted the jury’s conclusion was vitiated by the coroner’s failure to leave open to them the possibility of neglect.

In allowing the claim the court observed it was unfortunate that the coroner gave no reasons for declining to leave neglect to the jury. Indeed, the claimant only became aware of this intention when listening to the summing up. The court noted – unsurprisingly – that it would have been better practice to explain his decision beforehand. Looking at the facts of the case, the deceased had suffered significant weight loss before she died, her medical records had not been properly maintained or updated, and the policy on nutrition and hydration had not been followed. In light of that there was no reasonable basis for removing neglect from the jury’s consideration. Accordingly, the jury’s conclusion was quashed and a new inquest ordered.


A copy of the full judgment is not yet available. Nonetheless, the observations made by the court appear clear. The failure to give reasons in such a case will always leave a coroner vulnerable to challenge. The duty to give reasons serve two purposes. They explain the court’s decision. Perhaps more importantly, however, the process of formulating formal reasons can also assist in correcting potential judicial error. Having to apply the particular facts of a case to the legal principles in question can guard against irrational decisions of this nature arising in the future.

Christopher Geering 


Categories: Articles | News