High Court orders second inquest over Mid Staffs death

John Moore-Robinson died from a ruptured spleen in April 2006 after being told by a junior doctor that he had bruised his ribs following a mountain bike accident. He was never given a CT scan and sent home despite sweating profusely, vomiting and being in too much pain to walk.

Mr Moore-Robinson’s parents Frank and Janet Robinson have fought for a new inquest after the case was cited during Robert Francis QC’s first inquiry into care at the hospital in 2010.

After the family made an application to the attorney general Dominic Grieve, the High Court quashed the original verdict on Wednesday, ruling a new inquest should take place. It is expected to be opened and adjourned in Leicester - where Mr Moore-Robinson died - on Monday.

In his report into his public inquiry into the trust released in February, Mr Francis said Ivan Phair, a consultant at the trust, prepared a report for the South Staffordshire coroner. This stated Mr Moore-Robinson’s “unfortunate, untimely death may have been avoided, had he been more properly assessed” upon arriving at accident and emergency.

Mr Francis said former trust board secretary and head of legal services Kate Levy wrote to the consultant suggesting this claim was removed from his report. She wrote: “… as reports are generally read out in full at the inquest and the press and family will be present, with a view to avoiding further distress to the family and adverse publicity I would wish to avoid stressing possible failures on the part of the trust.”

Ms Levy did not send either the original or amended version of the report to the coroner, Mr Francis said.

Trust solicitor Stuart Knowles, who took on the file, also failed to pass the consultant’s report on to the coroner. Mr Francis’ report said a document submitted to the coroner by Mr Knowles avoided the “forthright critical opinion” of Mr Phair. Mr Francis said the fact that he told the coroner he had consulted Mr Phair had the effect of “implicitly associating Mr Phair with this position”. “Given what he knew to be Mr Phair’s view of the case, this was unwise,” Mr Francis wrote.

The coroner, Andrew Haigh, went on to record a narrative verdict in 2007.

Mr Haigh, is believed to have opposed the application to hold a second inquest. In his appearance at the inquiry he said it would have been “preferable” to see the reports although he believed his verdict would have been the same.

Ms Levy was sacked by Mid Staffordshire in 2010 but later received a £103,000 payout from an employment tribunal after the trust admitted unfair dismissal.

She and Mr Knowles were investigated by Staffordshire Police but no charges were brought.

In evidence to the public inquiry they both argued their primary duty was to the hospital and not to the coroner or the family.

In his report, Mr Francis QC concluded the reports should have been sent to the coroner. He found Mr Knowles’ evidence was “evasive” and had “the unattractive characteristics of special pleading”.

He said the way the trust handled the case demonstrated “the sad fact that, for all the fine words printed and spoken about candour, and willingness to remedy wrongs, there lurks within the system an institutional instinct which, under pressure, will prefer concealment, formulaic responses and avoidance of public criticism.”

He recommended “unequivocal guidance” be given to NHS lawyers making clear openness should be a priority over any “perceived material interest”.

Frank Robinson told HSJ: “It has been a six year battle for the truth and has been a long hard road.

“We just want the evidence that was available at the time to be considered. All we want is a thorough investigation of what went wrong. We owe that to John.”