Case Name and Citation
R (on the application of Maguire) v HM Senior Coroner for Blackpool and
Fylde (2019) EWHC
Court and Judges
High Court of Justice Queen’s Bench Divisional Court: Lord Justice Irwin, Mrs
Justice Fabrey and His Honour Judge Lucraft QC (sitting as a judge in the High
Court)
Parties
Main Parties:
Claimant: Mrs Muriel Maguire (mother of the deceased Jacqueline Maguire)
Defendant: HM Senior Coroner for Blackpool and Flyde
Interested Parties:
i.
United Response (first interested party)
ii.
Northwest Ambulance Service (second interested party)
iii.
Blackpool Victoria Teaching Hospital (third interested party)
iv.
Dr Sarfaraz Adam and Dr Susan Fairhead (fourth interested party)
Material Facts
The case is about a woman named Jacqueline Maguire, who died at the
age of 57 on the 22 February 2017 due to a perforated ulcer. Jacqueline
Maguire, who is also known as Jackie, is a woman with down syndrome and she
has moderate learning disabilities which renders her incapable to be left alone
without any supervision. She was sent to a care home under the authority of the
Blackpool City Council and has been there for over 20 years since 1993. At the
care home, she was deprived of her liberty as she was locked in her room. This
deprivation towards her as a person with Down’s Syndrome whose
communication and cognitive abilities are severely compromised can be
justified through
A week before to her death, Jackie had complained of a sore throat and
had a limited appetite. She also had a raised temperature, diarrhoea, and
vomiting. The care home staff were not trained medically or nursing. After a
delay, Jackie’s carers had telephoned her General Practitioner (GP) who
diagnosed
Jackie
infection and she
to
have
viral
gastroenteritis
and
urinary
tract
prescribed medication. Later that evening, the carers
contacted the National Health Service, NHS111, who dispatched an ambulance.
The two-person crew who arrived were not aware that Jackie had learning
disabilities. Jackie refused to be taken to hospital and the ambulance crew were
not qualified to sedate her to convey her to the ambulance. The paramedic thus
sought an out of hours GP’s advice, who advised it to be inappropriate to use
physical force on Jackie. A final attempt to persuade Jackie to go to hospital
was made when her mother rang. The following morning, the care home staffs
found Jackie soiled on the floor and she was taken to hospital where she died in
the evening.
Jackie’s family members were certain that her death could be
avoided, so an inquiry on her death was held by Mr. Alan Wilson, the Senior
Coroner for Blackpool and Fylde, to find out the manner and the cause of her
death. During the preliminary stage, the Coroner decided that Article 2 of the
ECHR had been engaged in relation to whether the state is to be blamed for the
faults of the relevant parties that took part in the chain of events.
. In the case of R (on the application of Parkinson) v Senior Coroner of
Kent, it was confirmed that other inquests will only become Article 2 inquests if
there is evidence of systemic failures of processes and systems to protect life.
And a case of ordinary medical neglect will not trigger Article 2. This decision
was released by the High Court 5 days before the inquest of Jackie’s case took
place. The Coroner then decided to change his decision by referring to this case
and held that Article 2 was not engaged.
The next issue is the question of neglect of medical authorities. The
coroner decided that there was insufficient evidence on this matter and refuse to
put the question before the jury. Therefore, the jury found that Jackie’s death
was due to natural causes. Mrs Maguirel has filed a judicial review application
to challenge the two grounds of the coroner decision.