Chapter 8: The inquests

On the basis of summaries provided by the police, Mr Horsley quickly formed the view that ten of the Operation Rochester cases would require an inquest. These were the cases that fell into one of the categories considered in the police investigation and described in Chapter 5, namely Category 3B (negligent treatment where the cause of death was unclear). However, little, if any, consideration appears to have been given in the early stages of the Coroner’s involvement to the possibility that some of the other cases assessed by the Key Clinical Team (KCT) may have required an inquest. The KCT, headed by Professor Robert Forrest, Professor of Forensic Toxicology at the University of Sheffield, had been instructed by the police to consider the evidence in relation to the 91 deaths investigated as part of Operation Rochester.

The information provided to Mr Horsley in updates from the police was that the Category 2 cases were “considered to be sub optimal (care) but did not present evidence of unlawful criminal activity” (PCO000081, p1). The file of material the police provided to Mr Horsley on 11 April 2007 only contained evidence in relation to the ten Category 3B cases. It also contained an “Investigation Overview” of Operation Rochester prepared by Det Supt Williams. The overview document referred to the fact that during the third investigation:

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.

Of the 57 cases that the KCT considered fell into Category 2, 20 were categorised as being 2B (sub-optimal care where the causes of death are unclear). One case was categorised as 1B (optimal care where the cause of death is unclear). In a number of the Category 2 cases, the KCT was unable to provide any opinion on the cause of death because of the paucity of medical records (HCO001601). For further explanation of how the KCT operated, please see the Key Clinical Team Table on this website.

On 7 June 2007, Susan Rolling of Hampshire Constabulary asked Mr Horsley how many inquests there would be. He responded as follows:

The Panel notes that Mr Horsley appears to have taken a restrictive view of his duty in this regard. 

A letter to the Ministry of Justice dated 15 June 2007 discloses the extent to which the Coroner was relying on the view taken by the police. Mr Horsley explained that:

In support of the proposition that the inquests should proceed by way of a public inquiry, Mr Horsley repeatedly referred to the fact that further inquests might well need to be carried out, in addition to inquests for the ten deceased who had been identified as Category 3 cases. At the meeting with the Ministry of Justice on 21 August 2007, Mr Horsley said that “while 82 of the 92 did not pass the test for criminal investigation, many more deaths than the remaining 10 might well warrant an inquest, with its lower evidential hurdle” (PCO000128, p2). He went on to say that he thought it “dangerous” only to consider the ten cases, as “other families would call for inquests and he could not see how to resist. There would be judicial review cases against him” (p3).

Further, in a letter dated 26 November, Mr Horsley stated:

Following the opening of the ten inquests in May 2008, letters were sent to the Coroner’s Office enquiring whether there would be any further inquests. One such enquiry came from the legal representatives of Gillian Mackenzie, who enquired whether Mrs Mackenzie’s mother, Mrs Richards, was going to be the subject of an inquest (BLC003749). Mr Horsley’s initial response to Det Supt Williams was that “my understanding of the evidence presented to me as a result of Operation Rochester is that Mrs Richards’ death could not be ascribed to anything other than natural causes” (PCO000243, p2).

As the inquest that was eventually held into the death of Mrs Richards showed, this initial assessment was wrong and demonstrates the very limited extent of the information that Mr Horsley was given in relation to the other 81 deaths that had been investigated as part of Operation Rochester. In the case of Mrs Richards, Mr Horsley had to ask for comments from the police in relation to criticisms raised in a letter received from Bindmans LLP, the solicitors then acting for Mrs Mackenzie. When the police eventually responded, in October 2008, they noted that Professor David Black, a consultant in geriatric medicine, had concluded that the dose of diamorphine given to Mrs Richards was sub-optimally high but that “he did not believe this contributed in any significant way to Mrs Richards death and that her death was by natural causes” (PCO000212, p2). Nevertheless, Mr Horsley did proceed to hold an inquest into Mrs Richards’ death as, when the police provided him with further information, it transpired that her death would have been reported under his reporting criteria.

The police appear to have provided Mr Horsley and Mr Bradley with very limited information in relation to the other 81 cases. The approach of the Coroner’s Office was that there would be no enquiry by the Coroners beyond the ten deceased who had been identified as Category 3B cases. At the first pre-inquest hearing on 14 August 2008, it was indicated to the Coroner that six other families had said they were concerned about their relatives who had been patients at the hospital and had subsequently died. Mr Bradley was provided with the details of the family members concerned, but the Coroner was not pressed to make a decision as to whether their cases should be included within the inquest hearings that had been listed.

The note of the pre-inquest hearing on 14 August 2008 records the Assistant Deputy Coroner Mr Bradley, who conducted the hearing, as stating that the decision in respect of the ten deceased people included in the inquest was that of the Secretary of State, and not his decision (PCO000736, p2).

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.