High Court overrules coroner over patient's death

Coroners may have to hold more inquests when patients die after apparent failures in routine monitoring, following a High Court ruling last week. Lord Justice Kennedy and Mr Justice Morison ruled that a coroner was wrong to refuse an inquest into the death of a woman who died of a brain haemorrhage after giving birth to twins by caesarean section.

The coroner for inner north London, Stephen Chan, decided that an inquest on Laura Touche, aged 31, who died at the private Portland Hospital in London, was unnecessary because the death was from natural causes. Mrs Touche, an American, was brought back to her private room after the operation and was not checked by staff for two and a half hours. NHS requirements stipulate monitoring every 15 minutes in the first hour. After she complained of a severe headache, her blood pressure was taken and hypertension diagnosed. She was given drugs but experienced a brain haemorrhage and died a week later on 15 February 1999 after being transferred to an NHS hospital.

Dr Chan wrote to her husband, Peter Touche, that “accepting that the haemorrhage was secondary to hypertension and that there was delay in its discovery, the cause of death was still due to natural causes, and was not an unnatural one.” In a statement to the court, Dr Chan said that he accepted that there was no record of intraoperative monitoring and that “postoperative monitoring would appear wholly inadequate, not having started for an unacceptably long period following delivery.”

Ordering a full inquest, Lord Justice Kennedy, said: “It seems to us that if the coroner did not adopt an approach which was correct in law—and the documentation does not clearly indicate otherwise—then he reached a conclusion which was irrational.” He added: “Where, as in this case, a patient is in hospital suffering from a condition which, if not monitored and treated in a routine way, will result in death, and, for whatever reason, the monitoring and treatment is omitted, then, it seems to us, the coroner must hold an inquest—unless he can say that there are no grounds for suspecting that the omission was an effective cause of death.” The case has led to renewed calls for more stringent regulations governing private hospitals.