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Coroner finds that a stab victim was unlawfully killed and that there were causative failures by an NHS Trust


Dominic Adamson KC, instructed by Patrick Maguire and Kate Daflon of HCC Solicitors, acted on behalf of the wider family of Lesley Ann Spearing who had suffered fatal injuries when she was stabbed by her son (who was separately represented).  Juliet Wells also acted for the wider family at the pre-inquest hearings.

Prior to the fatal incident the deceased’s son had been diagnosed with a schizoaffective disorder.  At the time of the incident he was suffering from a relapse of his psychosis.  The Crown Court ruled that the son was not fit to enter a plea.  Therefore, the matter proceeded to a trial of the facts.  The Crown Court jury accepted that the son had stabbed the deceased.  He was subject to a hospital order.  It was against that background that the matter proceeded to an inquest. 

The Coroner accepted that the investigative duty under Article 2 ECHR was engaged as a result of concerns relating to the standard of treatment provided by Kent NHS Trust to the son in connection with his mental health condition.  For some time prior to the incident the son had been the subject of a Community Treatment Order (CTO) under the Mental Health Act 1983.  The son’s designated care co-ordinator was inexperienced and did not understand the terms of the CTO.  There were repeated failures in the medication regime which was put in place to treat the son’s mental health disorder and psychosis and a lack of clarity over the identity of his Responsible Clinician.  Dominic Adamson KC argued that the Trust failed to take adequate steps to address a deterioration in the son’s mental health condition and that this this put others, an in particular, the deceased at risk.  Having heard the evidence, the Coroner accepted that there were significant failures in the Trust’s treatment of the son and that these failures were causative of the deceased’s death.

It was common ground that that if the son was insane at the relevant time then a conclusion of unlawful killing was not appropriate.  However, it was argued on behalf of the son (who was able to participate in the inquest and provide instructions to his legal team) that a conclusion of unlawful killing should not be reached.  It was suggested that the court could not be satisfied that at the time of the stabbing that the son knew (i) of the nature and quality of the act that he was performing and/or (ii) that what he was doing was wrong.  In other words it could not be satisfied that the son was not insane applying the M’Naghten test.  Given that this was an inquest the son bore no burden to prove insanity.  This is in contra-distinction to a Crown Court matter where a defendant does bear the burden of proving insanity.  The Court accepted Dominic Adamson KC’s argument that, as a matter of law, there was sufficient evidence upon which a Court could be satisfied on the balance of probabilities (see R (Maughan) v HM Senior Coroner for Oxfordshire) that the son knew both of the nature and quality of the act that he performed and that he knew that it was wrong.  In other words, although he was suffering from a disease of the mind the Court could be satisfied on the evidence that he was not insane at the relevant time.  The Coroner agreed and concluded that the deceased was unlawfully killed.

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Dominic Adamson KC

Call 1997 | Silk 2020

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Juliet Wells

Call 2016

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Related Practice Areas

Inquests & Inquiries




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