The documents show little justification for the delay between the Crown Prosecution Service decision in December 2006 and the eventual start of the pre-inquest hearings listed for 14 August 2008.
The documents show little justification for the decision to hold the inquest into the death of Gladys Richards separately.
The Panel notes that the test for whether a case should be the subject of criminal prosecution is significantly different from the test for whether it should be the subject of an inquest by a Coroner. A Coroner is required to hold an inquest in cases where he/she has reasonable grounds to suspect that the deceased has died a violent or unnatural death or has died a sudden death of which the cause is unknown. A death that the police consider does not involve evidence of ‘unlawful criminal activity’ or ‘negligence’ by the treating clinician could still necessitate an inquest by the Coroner.
On the basis of the papers that the Panel has seen, it appears that the Coroner and Assistant Deputy Coroner were given very little information by the police in relation to the other 81 deaths, but no effort appears to have been made to make any further enquiries in relation to those deaths. The findings of the Key Clinical Team in relation to each of the 81 deaths clearly showed that, in their expert opinion, the cause of death was unclear in far more than the ten Category 3B cases. The Coroner should, therefore, have considered these cases for inquests. The findings of the Key Clinical Team in this regard were held by the police and were readily accessible; they were forwarded to the General Medical Council for the purposes of the General Medical Council’s investigation into Dr Jane Barton’s fitness to practise and, even if they were not provided to the Coroner, would have been readily available to him.
Day one of the inquest hearings was 18 March 2009. The Panel notes that this was over two years after the Coroner took a provisional view in relation to the requirement for him to hold inquests into the ten deaths.
The documents show the Coroner’s opinion on those verdicts that would have reflected the families’ concerns: “trite Home office category verdicts are not going to answer people’s questions. You can walk away with an open verdict, you can walk away with unlawful killing, but it actually does not answer the questions that people want to have answered.”
The documents show that the Coroner declined to adopt a wider approach to the inquests and the opportunity offered by Rule 43 of the Coroners Rules 1984 to prevent similar deaths in the future.
Mr Bradley had no reports before him from experts entirely independent of the criminal investigation and chose to rely upon two experts whom he knew the police had instructed. Neither Professor Gary Ford nor Dr Keith Mundy, for example, were called to give evidence in person. In resisting requests to widen the expert evidence, for example to include that of Professor Robert Forrest, the Coroner appears from the records to have used reasons based on his own view as to why some reports were inadmissible and should not be relied upon. As a result of the approach taken, the records show that no independent expert evidence from a toxicologist or pharmacologist was sought, despite the central issue of the prescribing of diamorphine.