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(29) Defects of Coroner’s Summing-up
When at the conclusion of the inquest the Coroner summed up he failed to
direct the jury as to the availability of a verdict of "lack of care" or of
combining "lack of care" with "accidental death" in some such formulation as
"accidental death due to lack of care" or "accidental death aggravated by lack
of care". It is respectfully submitted that this was a fatal and unlawful
omission. He had a duty to so direct the jury wherever there was evidence
that a culpable negligence short of the level necessary to justify a verdict of
"unlawful killing" was present and caused or contributed to the death of the
deceased. In the alternative, if this wider submission is not accepted, then it
is respectfully submitted that he did at least have an undoubted duty to direct
the jury as to the availability of a verdict incorporating reference to "lack of
care" if they found that there had been some culpable omission as a result of
which an "opportunity" to render essential medical care and thereby prevent
fatalities had been "lost" (the test of a "lost opportunity to render care" was
laid down in the case of R -v- Southwark Coroner ex parte Hicks (1987) 1
WLR 1624 and is applicable here). On the evidence before the jury, despite
the limitations due to the imposition of the cut-off point, it was open to them
to conclude that, but for the delays in the arrival of the emergency services,
the deceased, or at least some of them, would have survived.
(30) Your Memorialists James and Anne Williams also draw attention to the
further evidence that has come to light since the inquest which is summarised
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