Law Report: Ambulance delay did not justify holding inquest: Regina v HM Coroner for Greater London (Inner London North District), ex parte Thomas. Court of Appeal (Lord Justice Dillon, Lord Justice Farquharson and Lord Justice Simon Brown), 15 December 1992

Where the practical medical cause of a person's death was a natural cause, such as a severe asthmatic attack, then the fact that it was accompanied by circumstances, such as the delayed arrival of an ambulance, which might have contributed towards causing the death, did not render the death 'unnatural' within the meaning of section 8(1)(a) of the Coroner's Act 1988, so as to require the coroner to hold an inquest.

The Court of Appeal allowed an appeal by Douglas Chambers, Her Majesty's Coroner for Greater London (Inner London North District), against an order of the Queen's Bench Divisional Court (Independent, 14 April 1992), granting an application for judicial review by Doris Thomas, that an inquest be held into the death of her daughter, Mavis Thomas.

Terence Coghlan (Hempsons) for the coroner; Edward Fitzgerald (Deighton Guedalla) for the applicant.

LORD JUSTICE DILLON said Miss Thomas, who was 17 when she died, had been a life-long sufferer from asthma. She had a severe attack of asthma at about 1am on 9 April 1989. Her sister and a neighbour attempted to summon the ambulance service by dialling 999; but a recorded message from the ambulance service stated: 'There is no one here at present. Please hold on and we will answer your call as soon as we can.' This was repeated several times while they waited. They then decided to take Miss Thomas to hospital by car.

On the way, Miss Thomas collapsed and the car was stopped. She was laid out on the pavement and the police were summoned. While attempts were made to revive her, the police made three calls urgently requesting an ambulance. An ambulance finally arrived at 1.33am.

Miss Thomas had stopped breathing a minute or so earlier and when she arrived at hospital, at 1.40am, she had no pulse and was not breathing. Attempts to resuscitate her were abandoned at 1.55am.

The pathologist's report gave as cause of death 'status asthmaticus', ie a prolonged asthmatic attack. But there was medical evidence from two consultants at the hospital that had Miss Thomas arrived before her cardiac arrest, she would not have died, and even if she had arrived within five minutes of her cardiac arrest, there was a good chance she could have been saved.

Miss Thomas's family were naturally very concerned at the failure of the ambulance to arrive in time to save her life. The question was whether there should be an inquest.

Under section 8(1) of the Coroner's Act 1988, a coroner was required to hold an inquest where, inter alia, 'there is reasonable cause to suspect that the deceased (a) has died a violent or unnatural death . . .' The only basis on which an inquest could be held in this case would be if it could be said that, because of the late arrival of the ambulance, there was reasonable cause to suspect that Miss Thomas died an unnatural death.

'Unnatural' was an ordinary word in the English language which should be given its ordinary meaning. There was no context in section 8(1) to suggest that the word 'unnatural' was being used there in any unusual sense.

In the context of death, 'unnatural' was obviously the antithesis of 'natural'. Since in most cases that would mean a violent death, which was expressly covered in section 8(1)(a), it was helpful to consider what non-violent deaths were none the less to be regarded as unnatural.

One obvious class was death from industrial illness (as opposed to industrial accident). In such cases an inquest was always held. A parallel would be the deaths of persons in a typhoid epidemic occasioned by contamination of the water supply in an area.

Inquests were also invariably held on persons dying of Legionnaire's disease, presumably because the disease was, thankfully, very rare in this country. But asthma was not very rare, and there was nothing unnatural per se in a person dying of asthma.

Another instance of unnatural but non-violent death was from 'lack of care' and the narrow sense used in R v Southwark Coroner, ex p Hicks (1987) 1 WLR 1624, as referring to the physical condition of the deceased as causing the death, but not as indicating a breach of duty by another person.

In this case, it could not be said that Miss Thomas was in the 'care' of the ambulance service in the sense that word was used in Hicks.

Whether Miss Thomas's death was natural or unnatural must depend on what was the cause of death. That was essentially a practical question of fact. The complaint was that the chance of saving her life was lost because of delay in the ambulance's arrival.

But it was easy to think of a variety of scenarios as a result of which an ambulance could have arrived too late to save a patient, such as: (i) the distance from the ambulance centre to the patient's home was too great; (ii) there was more traffic than normal; (iii) the ambulance was diverted by flooding caused by a burst water main; (iv) a new computer installed to handle emergency calls had malfunctioned; (v) the ambulance crew were inefficient and its management was slack.

In each case, common sense indicated that what caused the patient's death was the asthmatic attack, not the delay. But the attack was a natural cause of death and was not turned into an unnatural death by any of the facts suggested in the five scenarios. Even when all the other evidence was taken into account, the cause of death was still the asthmatic attack and the death was not unnatural.

Lord Justice Farquharson and Lord Justice Simon Brown concurred.

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