On 6 February 2019 the Administrative Court (Supperstone J) granted Mrs Maguire, the Claimant, permission to challenge by way of judicial review two decisions of the Senior Coroner for Blackpool and Fylde, taken at the conclusion of the inquest (July 2018) which he conducted into the death of the Claimant’s daughter, Jackie Maguire: these were the Coroner’s decision that Article 2 (the right to life) was not engaged and second, the Coroner’s decision not to leave the verdict of neglect to the jury.   

It was argued for Mrs Maguire, that the Coroner when taking the decision that Article 2 was not engaged, wrongly applied the law as set out in R (Parkinson) v HM Senior Coroner for Kent [2018] 4 WLR 106 to the effect that in ‘healthcare’/’medical negligence’ cases Article 2 is not engaged unless some kind of exceptional systemic failure can be demonstrated. This is wrong and a misunderstanding of the law.

The decision of the Grand Chamber of the European Court of Human Rights in Lopes de Sousa Fernandes v Portugal (2018) 66 EHRR 28, adopted in Parkinson, made plain that different considerations arise in certain other contexts, in particular with regard to the medical treatment of persons deprived of their liberty, or of particularly vulnerable persons under the care of the state, where the state has direct responsibility for the welfare of these individuals. Jackie Maguire fell squarely within this definition.

As to the second decision, it was argued that the Coroner had wrongly failed to consider whether the various undoubted individual failings in care to Jackie  Maguire, by the various agents involved in her care -from the support workers, to the GPs, a paramedic crew attending and various doctors at the hospital, taken as a whole, were capable of being viewed by the jury as amounting to a serious failure to provide basic medical care to a vulnerable person. This was plainly a case in which there was sufficient evidence to leave the question of neglect to the jury.

The judicial review hearing is about to be listed and will highlight the failings in care to a very vulnerable woman, and the fact that the evidence shows that this is worryingly part of a much wider picture of neglect which should lead to an Inquiry if future lives are to be saved amongst this vulnerable group. The case law correctly applied shows that Art 2 was engaged and that there were several gross failings in care which could reasonably lead to a finding of neglect by the jury.

Carol Boys, CEO of the Down’s Syndrome Association said:

We are encouraged to hear permission has been granted  for a judicial review to look  at certain decisions made by the coroner at the inquest in to the death of Jacqueline Maguire who had Down’s Syndrome. The Down’s Syndrome Association has ongoing and serious concerns about the premature deaths of people with Down’s Syndrome. We very much appreciate the efforts of Saimo Chahal QC on behalf of Jacqueline’s mother, Mrs Muriel Maguire.

The Background Facts

• Our client is Muriel Maguire, the Claimant. She was the mother of Jackie Maguire. Jackie Maguire, (DoB 28.04.1964) was aged 52 at the time of her death on 22 February 2017. She had Down’s syndrome, curvature of the spine and had learning difficulties.Despite these health problems, Jackie Maguire led a happy and fulfilling life. She was much loved by her mother and siblings and had a strong and independent personality. She lived in a care home run by United Response at 85 St Anne’s Road East, Lytham St Anne’s, Lancs. She had been placed there by the Lancashire County Council, Adult Safeguarding Services.
• On 4 April 2016 a Deprivation of Liberty Safeguard had been signed in respect of Jackie Maguire. The Social worker and psychiatrist confirmed that Jackie Maguire lacked the mental capacity to make decisions about where she should live.

Circumstances leading to Jacqueline Maguire (JM’s) death

• In 2016-2017, Jackie Maguire complained constantly of pains. By November 2016, there was sufficient concern to warrant a hospital appointment to investigate a possible diagnosis of cancer.
• On 20 February 2017, Jackie Maguire was ill in bed and refused to get up. She did so later. She asked for a doctor but this was not arranged by support staff.
• On 21 February, Jackie Maguire was again reluctant to get out of bed. She had seizures at 2pm and 7:30pm. The GP was contacted and advised calling 111 the first time and wrote a prescription and carers were told to bring Ms Maguire to the surgery on the second occasion. This was not practicable. Paramedics attended at approximately 17:50, but Jackie Maguire refused to go to hospital- she lacked the mental capacity to make that decision. The paramedics contacted the out of hours GP, who advised that Jackie Maguire should not be forced to go to hospital. However, the GP was not told that there had been a second seizure; she was only advised about the first seizure. She did not advise that despite Jackie Maguire’s refusal, she could be taken to hospital in her best interests, due to her lack of mental capacity to make decisions about her health, care and treatment.

• Jackie Maguire was allowed to go to bed. On 22 February at 6:30am, the support worker, discovered Jackie Maguire in her bed, incontinent. She was weeping and appeared to have a further seizure. A 999 call was made and paramedics arrived at 8:10 and at 8:30, despite Jackie Maguire’s refusal to go to hospital, they recognised that she could be taken to hospital in her best interests. She was escorted to the A&E Department of Blackpool teaching hospital.

• It was noted that Jackie Maguire had had 10 days of diarrhoea and vomiting over the past two days. Jackie Maguire was misdiagnosed initially with Urosepsis. She had been complaining of abdominal pain. She was found to be severely dehydrated with kidney failure and profound metabolic acidosis. She was managed on fluids and antibiotics. She was left alone for some hours. She suffered a cardiac arrest at 18:31pm. Resuscitation attempts were made but she was pronounced dead at 19:40pm. The cause of death in the post mortem report is given as a perforated gastric ulcer with peritonitis as well as pneumonia.

• An Inquest into the death of Jackie Maguire was opened by HM Senior Coroner at Blackpool and Fylde Coroner’s Court, Blackpool. There was a Pre Inquest hearing on 18 December 2017.The Inquest hearing took place over 7 days between 20 June – 2 July 2018.

• Ms Boys, CEO of the Down’s Syndrome Association has expressed deep concern over the death of Jackie Maguire. There is wider concern about the premature deaths of people with Down’s Syndrome which makes for uncomfortable reading in the Bristol University’s Leder report and The National Confidential Inquiry into the death of people with learning disabilities.

Saimo Chahal QC (Hon) represents Mrs Maguire in the Inquest and the Judicial Review Claim. Jenni Richards QC is counsel, with Victoria Butler Cole and Nicola Kohn- 39 Essex Chambers.