Five-day inquest into prisoner death held at the RCJ: Coroner to write an RPFD

Peter Carter Q.C. and Abigail Bright, instructed by Graeme Rothwell, McMillan Williams Solicitors, litigation department, represented the daughter of the deceased, O. 


At the time of O’s death, O was a serving prisoner at HMP Wandsworth. O died of natural causes, after a delayed diagnosis of oropharyngeal cancer. 


Her Majesty’s Assistant Coroner for the City of Westminster gave the first ruling to create case law on how and why the jury is entitled to reach conclusions on “the circumstances” of “where” a person died.  


Evidence was heard from a member of the Home Office as to whether it was more likely than not that O would have been released early on compassionate grounds had O’s diagnosis been timely and not delayed.  

The evidence was that the Home Office would have processed the application within a week of receiving it and that O would have been recommended for early compassionate release. 


Two of O’s treating physicians gave evidence that they would have supported any such application. 


Her Majesty’s Assistant Coroner ruled: 'The words “in what circumstances” in section 5(2) of the Coroners and Justice Act 2009 is a direct reference to sub-section 5(1)(b) of the Act. They are to be interpreted collectively. In those circumstances, the jury is entitled to look at the “circumstances” of “where” someone came by their death.’


The ruling establishes that “where” a person came by their death is not simply a matter of geographical fact. 


For the full text of the judgment, click here


The jury’s conclusions were as follows: Natural causes; died on 20.11.2014 at St Georges Hospital; delays in diagnosis and obtaining early compassionate release meant that the deceased died in hospital and not in a place arranged by him and his family.  

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