Successful Judicial review of Coroners decision for Attwaters !

Another great result for Attwaters Accidents with the successful judicial review of this clinical negligence case.

The Attwaters Accidents’ (AJH solicitors) medical negligence team, represented the family of Gabrielle. In this tragic case, Gabrielle died after using her coat belt as a ligature.

In this tragic case, Gabrielle died after using her coat belt as a ligature. This occurred while she was a patient on a mental health ward, on 30 January 2019.

The inquest into Gabrielle’s death took place in March 2021. During the evidence, the clinicians who had cared for Gabrielle accepted that she should not have been allowed access to the coat belt.

HM Assistant Coroner for Surrey went on to decline to make a finding on this evidence, because she decided that, even without access to the belt, she was not satisfied that Gabrielle would not have achieved the same outcome by some other means.

The family applied for judicial review of this decision on the grounds that the Coroner had failed to reach a finding on a central issue of access to the ligature, and that she misapplied the law of causation in coronial law.  We argued that the Coroner was obliged to find that access to the coat belt was a failing of the hospital, and that access did cause Gabrielle’s sad death.

The Coroner defended her decision and actively contested the claim for judicial review until shortly before the final hearing. At that stage, the Coroner conceded and agreed to correct the record to reflect the findings sought by the family.

The record of inquest will now be corrected to record that it was a failure to remove the ligature, and this caused Gabrielle’s death.

The family was represented by Chris Channing of counsel ,  instructed by Goksel Karova and Joanne Westbrook of Attwaters Jameson Hill Solicitors.


Attwaters Accidents is the Medical Negligence department of the trusted, long-established firm Attwaters Jameson Hill.

You can trust us to work for you. But don’t take our word for it – take a look at our many successful claims. See just how good we are.


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