Wilson v HM Senior Coroner for Birmingham And Solihull

Judgment

Lord Justice Burnett :

Ian Wilson, the claimant in these proceedings, is a consultant cardiothoracic surgeon formerly employed by University Hospitals NHS Foundation Trust [“the Trust”] based at the Queen Elizabeth Hospital, Birmingham. This claim is concerned with the inquests held into the deaths of three of his patients by Her Majesty’s Senior Coroner for Birmingham and Solihull between 23 and 26 September 2014. The claimant complains about a single sentence included by the coroner in her short narrative verdicts in respect of each deceased:

“An historic failure to accurately record post-operative data for all patients resulted in a missed opportunity to identify potential problems at an earlier stage which may have resulted in [the deceased’s] operation being dealt with by a different surgeon.”

That part of the coroner’s conclusion flowed from evidence which had been admitted at the inquest in the teeth of opposition from the claimant. Mr Garnham QC, who appears before the court in these proceedings, but did not appear before the coroner, advanced three grounds in support of the contention that the sentence should be removed by quashing it from each of the narrative conclusions.

It was unfair to rely upon the evidence and reach the conclusion because the claimant was not given a meaningful opportunity to challenge it, in particular by exploring the underlying data which were said to support it;

The coroner failed properly to explore the evidence relating to the conclusion;

The conclusion of the coroner in this regard was irrational.

The coroner has taken no part in these proceedings but has provided a statement explaining her approach. Similarly, the families of the three deceased, each of whom was represented before the coroner, have taken no part but each has provided written support for the coroner. The Trust, whose medical director Dr David Rosser gave the material evidence, has also taken no part in these proceedings.

Background Facts

The claimant was employed as a consultant by the Trust between 1995 and October 2013. The three patients whose inquests were heard together were Peter John Brookes, Alan Charles Tringham and Alan Lucas. Each underwent cardiac surgery at the hands of the claimant. Mr Brookes’ operation was on 2 September 2011. He died two weeks later. The coroner recorded a narrative verdict:

“The deceased underwent extensive open heart surgery on the 2 nd September 2011. His surgery was more extensive than was