Cause of death overturned following inquest

11 February 2020

In early 2019 we were approached by a client, who was recently bereaved having lost her Mother. A post mortem concluded that the cause of death was "an old heart" even though the client's mother was very open about her intention to take her own life through starvation. The client wanted to challenge her Mother's cause of death but was unfamiliar with the coroner's process and had no idea where to start.

Client situation

The Client's Mother was an active member of the community, and was a supporter of Dignity in Dying. She had been diagnosed with Alzheimer's Disease and upon being diagnosed she communicated with all who knew her that she did not wish for the disease to concede her. She openly discussed that it was her wish to take her own life.

In December 2018 the Client's Mother attempted to take her own life, but was unsuccessful. She was extremely disappointed but was not deterred. In order to ensure that she was successful, she made the decision to stop eating. This was discussed with her friends, family, GP and carers. She was placed on end of life care, and she asked that all respect her decision.

Having not eaten for more than 30 days, and weighing just 27kg the Client's mother passed away with dignity, as she wished.

The death was referred to the Coroner who ordered that a post mortem be carried out to determine the cause of death. The recommendation at post mortem was that the death be registered as "old age."

The Client was unsure what she could do to challenge the decision and didn't know whether to put her mother's funeral on hold whilst the matter was investigated further.

How we helped

The client contacted Co-op Legal Services and her case was assigned to Emily Taylor. Emily was able to provide the client with tailored advice about the Coroner's role and processes. Emily explained to the client that as an interested person to the death, she was entitled to make representations to the Coroner if she did not agree with the cause of death.

We assisted the client in drafting a letter to the Coroner. The letter set out the events leading up to her Mother's death, her concerns and a formal request that the Coroner's decision to close the investigation on the basis that the cause of death was natural, be reconsidered.

The outcome

Upon receipt of the letter the coroner decided to reopen the investigation. The relevant medical records were sought and the pathologist was asked to reconsider his findings. Given the new evidence provided by the client, the Coroner held that the cause of death was likely to be unnatural and inquest went ahead. The conclusion at inquest was that the previous finding of an "old heart" be overturned and a new finding of "suicide by starvation" be registered as the cause of death.

Client testimonial

"I wanted to let you know that we had mum's inquest yesterday. It was a good experience with the right result - the cause of death has been changed to suicide by starvation. The pathologist thanked us for challenging his original finding of 'an old heart'.

"We would not have achieved this without your help. When I was very stuck and didn't know how to proceed, the practical help and encouragement you gave me was invaluable.

"Thank you so much."

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