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Inquests – Case Studies

Inquests – Case Studies

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Here at Farleys our specialist inquest solicitors have represented clients in a number of inquest cases, be they deaths in police custody, deaths in medical care or otherwise private inquest cases.  Below is a list of recent cases that Farleys have represented clients in, for further details regarding inquests please don’t hesitate to call us on 0125 460 6090 or email us

Below are details of a number of further inquests cases that Farleys Solicitors LLP have acted on:-

Willow Rosie Kemp – Death at Royal Manchester Children’s Hospital

Willow was just 20 months old and suffered from a number of complex conditions including a chromosomal defect and renal gastric normalities which required careful management of fluid and electrolyte balance particularly her low level serum Potassium.

Willow was being treated at the Manchester Children’s hospital and underwent a number of successful procedures whilst in their care. After undergoing the surgeries Willow was transferred to the Paediatric Intensive Care Unit.

Whilst admitted to the Intensive Care Unit Willow was prescribed a bespoke prescription routine that fell outside of typical guidelines. The prescription was to be administered with careful management and regular checks every 60-90 minutes. Unfortunately Willow was not check for over three overs during which her blood gas reading had climbed to an abnormal level.

The Specialist Registrar on duty failed to bring this to the attention of the Consultant immediately causing a delay in the corrective treatment. Willow’s ECG was noted as abnormal later revealing Ventricular Tachycardia. No palpable pulse was found and CPR efforts commenced but sadly were unsuccessful.

Upon inquest the NHS admitted full liability. To read a full account of this case study, click here.

Paul Davies – Death in police custody 

Paul Stephen Davies died as a result of an accident and the cause of death was contributed to by neglect. At 12:25 am on 28th September 2006, the deceased was pronounced dead at the Princess of Wales Hospital in Bridgend.

On 26th September 2006 between 07:30am and 07:42am, the deceased Paul Stephen Davies swallowed a package which became lodged in his airway (at an indeterminate point within this time range) during the execution of a drugs warrant.

The briefing was inadequate due to the gross failure of the intelligence systems in place at the time.

There was a lack of training provided to officers for

  • the forced search of the mouth of a detained person in a non-custodial setting
  • the control and restraint of a detained person in circumstances where an item is seen to be placed in the mouth

Paul Stephen Davies was not adequately controlled or monitored in the sitting room when officers arrived at (address).
Appropriate and timely action was taken by officers in seeking medical assistance for Paul Stephen Davies.
The coroner, Mr Peter Maddox, stated that he would use his rule 43 powers to write to the chief constable of South Wales Police and the other associated bodies to express his concerns of the lack of training offered to police officers dealing with this situation.

Mitchell John Turner – Death at Forest Bank Prison

Mitchell was found hanging from the hinge of his cell door at Forest Bank on the 15th July 2007. The jury heard four days of evidence from staff at Forest Bank, Paramedics and the pathologist.
After hearing all the evidence, the jury determined that Mitchell dies in the care of Forest Bank. On a number of occasions, Mitchell demonstrated a risk of self harm and appropriate precautions were not taken by the prison to negate this risk.

Terrance John Madden – Death in Custody

The jury have returned their verdict following the Inquest into the Death of Terrence John Madden.

The jury found that Mr Madden was experiencing severe alcohol withdrawal symptoms and that although prison staff recognised that his condition was deteriorating and that he was becoming more confused and distressed, he received no further medical intervention before he was found in his cell having sustained a serious head injury.

The jury had heard evidence that non of the healthcare staff in prison had had any specific training in the assessment and treatment of alcohol withdrawal. Staff gave evidence that although Mr Madden was suffering from auditory and visual hallucinations and he was plucking imaginary objects off the walls in his cell, this behaviour was normal for prison inmates undergoing alcohol withdrawal at HMP Liverpool.

The jury found that the significances in his deteriorating condition had not been appreciated by the healthcare staff.

Following his injury, Mr Madden was taken to University Hospital Aintree where there was a delay in his treatment, he became unconscious and died in Ormskirk Hospital on the 20th March 2005.

Petra Blanksby – Womens Death in Prison

Farleys Solicitors represented the family of Petra Blanksby a young woman who died in HMP New Hall prison.

Petra had a long history of self-harming and had been arrested following an attempt to kill herself by setting her bed on fire.  Whilst an inmate at HMP New Hall for 130 days she self-harmed on 92 occasions. She was described by one prison officer as a ‘death in custody waiting to happen’.

This case highlighted the issue of the lack of suitable places for young women who self-harm and following the Inquest, the Coroner indicated his intention to write subject to Rule 43 of the Coroners Rules to both the Prison Service and the Department of Health.

Kurt Howard – Death in a Psychiatric Hospital

Six years after he died the Inquest recently concluded into the death of Kurt Howard who died in Cefn Coed Hospital, Swansea.

The Inquest lasted 5 weeks and amongst their findings the jury concerned that,

  • The care plan and risk assessment in relation to Kurt were inadequately completed.
  • There was a lack of communication and training between the hospital staff.
  • Kurt was subject to an excessive and prolonged restraint in the prone position.
  • There was a delay in the staff calling the Ambulance.
  • The environment that the restraint took place was inadequate and unsuitable.

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