On 14 December 2022, judgment was handed down by the High Court King’s Bench Division in the case of R (Diarra Dillon) -v- HM Assistant Coroner for Rutland and North Leicestershire. The family applied for judicial review of the coroner’s decision to not issue a report for the prevention of future deaths (‘PFD report’) in relation to the inquest touching upon the death of Eshea Nile Dillon, which occurred in prison.
The Inquest
Mr Dillon who suffered from asthma and serious allergies was an inmate at HMP Stocken in Rutland. On 24 March 2018, Mr Dillon called for assistance by pressing his cell bell. A prison officer noticed that he was experiencing breathing difficulties and provided some advice but did not enter the cell as he was unaware that he had a discretion to enter a cell without another officer if, in his opinion, there was an immediate risk to life. He radioed the custodial manager and advised that Mr Dillon was struggling to breathe.
Approximately eight minutes later, other officers arrived who entered the cell. A ‘Code Blue’ was called to all other prison officers by radio which signalled a medical emergency, which triggered an ambulance being called, and CPR was commenced. Not all officers had first-aid training and it appeared Mr Dillon was not placed in the correct position for CPR. Just under an hour later, Mr Dillon was pronounced dead.
The inquest took place in October 2021 and the jury returned a narrative conclusion. The jury did not conclude that anything done (or not done) by prison officers contributed to Mr Dillon’s death. The coroner heard detailed evidence on whether she should make a PFD report in relation to staff understanding of emergency procedures, healthcare provision, first aid training for prison officers and reaching prisoners in emergencies, but she decided not to do so.
The Judicial Review
The claimant advanced two grounds for judicial review; that the coroner was irrational to conclude that the threshold for making a PFD report had not been met and that she erred in her approach by fettering her discretion and misapplying the law.
The claim was dismissed, and the judges found that the coroner’s decision was a lawful one. This judgment reaffirms the Chief Coroner’s Guidance and key principles surrounding PFD reports. We have summarised the key points as follows:
- The coroner was entitled to conclude that there was no need for action to be taken to prevent future deaths and that the threshold for a PFD report was not met
- The Ministry of Justice’s response demonstrated that steps had been taken to address the risk of future deaths by the introduction of spot checks. The Chief Coroner’s Guidance makes clear that if a potential PFD recipient has already implemented appropriate action, the coroner may not need to make a report. Whether a coroner needs to do so is a judicial decision for the coroner to make on a case-by-case basis taking into consideration all the circumstances
- The Prison Service’s ‘commitment to take action’ was a factor that the coroner was entitled to take into account in deciding that the formality of a PFD report was not needed
- PFD reports are ancillary to a coronial investigation and do not concern the rights of any person appearing at an inquest and no person has a right to be heard or to call any evidence that relates only to whether a report should be made
- The coroner must by statute form an opinion as to whether ‘action should be taken’ to prevent future deaths. These statutory words are sufficiently broad to entitle a coroner to consider what can practically be achieved – otherwise there is no real or actual action that could or should be taken
- PFD reports should be meaningful, and wherever possible, designed to have practical effect
We have a national team supporting healthcare and justice organisations in inquests – please contact us if you would like to discuss this matter further.
For further information, please contact:
Charlotte Brocklehurst, Hill Dickinson
charlotte.brocklehurst@hilldickinson.com
