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Normal For Norfolk

Posted by Dr No on 18 November 2009

norfolk.jpgIn the Good Old Days, NFN (Normal For Norfolk) was medical shorthand used to describe a patient who appeared peculiar, or odd. It now appears that NFN may apply not only to patients, but to other goings on in the good county of Norfolk.

Some seven weeks ago, Norfolk Coroner William Armstrong raised more than a few eyebrows with his narrative verdict in the inquest into the death in hospital of Kerrie Wooltorton, the 26 year old woman who killed herself by ingesting anti-freeze.

Wooltorton’s death was controversial because, although on a simple reading of the law, she appeared to have the capacity to refuse life-saving treatment, there were many other factors about her case that suggested considerable uncertainty over whether it was right for her doctors to allow her to die.

The effect of a narrative verdict is of course to preclude one of suicide – which does seem a little odd given the facts of the case. But there is more to it than that. By avoiding a suicide verdict, Coroner Armstrong neatly removed any risk that the doctors involved in Wooltorton’s care might find themselves in legal hot water over allegations of complicity with suicide – and so vulnerable to charges under the Suicide Act 1961.

Indeed, so keen was Coroner Armstrong to ensure that no one was in any doubt that the doctors had done the right thing in allowing Wooltorton to die, that on more than one occasion he declared that doctors had at all times acted within the law, and that any treatment to save Wooltorton’s life would have been unlawful.

To many observers, the effect of Coroner Armstrong’s findings was to give a legal green light for doctors to be what, for want of a better phrase, we might call passively complicit in a suicide – with, of course, active assistance but one short step away.

As it happens, Wooltorton’s verdict is not the first time Coroner Armstrong has, by way of a lenient – lenient, that is, towards the doctors involved - verdict, caused eyebrows to rise. In 2007, he recorded a verdict of death by natural causes following the death of an elderly woman – despite the fact that some, but not all, of the family alleged that doctors had deliberately starved the patient to death.

The patient, Olive Nockels, was admitted to hospital with a stroke, and according to members of her family, the doctors not only decided she was going to die, but that food and fluids should be withheld. Various court injunctions followed, and as a result tubes went in and out of Nockels faster than darts on a board. Nockels died some four days after the tubes were finally removed, and all food and drink withheld.

At the inquest, the doctors caring for Nockels said that she had been comatose, but a number of family members denied this, saying that she had been able to communicate, even to the extent of asking for food. Another doctor, called as a witness by the relatives, told Coroner Armstrong that Nockels had not died of a stroke, but with a stroke; and that the primary cause of death was lack of food and fluid.

No doubt Nockels was going to die sooner or later. But if, and it is an important if, there is any substance to the claims of the distressed relatives, then there are many who would see the death, hastened as it was by deliberate starvation, as one of euthanasia. And yet Coroner Armstrong returned a verdict of death by natural causes.

Interestingly, in both cases Coroner Armstrong was at pains to point out that his judgements were based on the law, and the law alone. Could it be that, in applying the strict letter of the law, and only the law, to what are undoubtedly complex cases, Coroner Armstrong has managed to sweep some awkward questions under the carpet? And that, in so doing, he has inadvertently managed to send out a signal that, at least in Norfolk, doctors who stand by and allow patients to die, and who hasten death, need not fear an awkward time at the hands of the Coroner?

As Dr No’s former colleague Auric Goldfinger used to say, the first time is happenstance, the second coincidence – and the third, enemy action. It would be a great wrong if what appears to be becoming Normal For Norfolk were to spread throughout the UK. Were it to do so, it would represent nothing less than the arrival of physician assisted suicide and euthanasia by way of an East Coast back door – and that, Dear Reader, cannot be allowed to happen.


I find this very disturbing - why as she had a history of self harm was Ms.Wooltorton deemed capable of thinking properly?

This case was nothing to do with the Mental Capacity Act even if it had been in force. This is to do with the inability to make decisions because of brain damage or imapairment as in Alzheimners for example

Her attempted suicide was to do with her Mental State and she would then have been helped under the Mental Health Act. Was this properly considered?

They could have got a Judicial Order, or injunction, they could have then treated her.

The Coroner had a duty to Ms. Woolterton to thoroughly investigate all the alternatives including those which would have prevented her death.

Why did he go with the hospital's interpretation of the Law?
Was this a judgement he made in consideration of the fact that she had died, and it was no use looking to far into the problem, even if the hospital and he were wrong on a point of law.?

Any doctors or lawyers out there with their views please?

If it's such a great law, why are there efforts afoot to have it amended?

Intertwingler - The point about KW's case is that things were grey (as opposed to being B&W). A history of self-harm doesn't ipso facto prove she didn't have capacity - but that history plus her other labels/diagnoses (depression and emotionally unstable personality disorder - note it is called emotionally unstable personality disorder) do raise at the very least a question of uncertainty.

No one has explained why KW was not assessed under the MHA 1983. Indeed, there are those (including Dr No) who would say that, on the face of it, it was negligent not to assess her, given her history and presenting suicidal behaviour. The reason it appears negligent is that (a) she was under the care of doctors (b) those doctors had a duty of care which included a full assessment including whether she had a current treatable mental disorder and (c) in failing to provide that assessment, they precluded the option of detention under the Act, and so by failing in their duty of care caused what might otherwise have been an avoidable death.

Absolutely right that the hospital lawyers should have gone to court to get a court order. Had it been a B&W case (ie no history of mental illness, no possibility of concurrent mental illness, a clearly sane individual of sound mind) then yes, maybe a court need not be involved. How the hell they thought they had the right to decide in the face of barn-door obvious uncertainty is quite beyond Dr No.

Coroner Armstrong has rubber stamped the hospital lawyers (who as noted were acting way above their pay grade) decision, which raise questions about his conduct in approving laywers acting above their pay grade. He has said that his finding are based exclusively on the law. That suggests a major defect in that there is as much medicine as their is law in case such as KW - but Coroner Armstrong explicitly limited himself to the law. That, to Dr No, raises the question of the adequacy of the Coroner Armstrong's enquiry. Did he, for example, consider the medical side of things? Things like taking a history, examining the patient (including a mental state examination), and differential diagnosis? It would appear not; all he considered was the legal question of capacity - which calls into question his findings.

Coroner's Reports etc are kept secret for 75 years which in effect limits our ability to assess patterns of behaviour in coroners to press reports and first hand account of those who were present.

According to his potted biography here, he is a lawyer (ie not a doctor) coroner. One wonders how much medical training coroners from a legal background get? Perhaps not enough?

He is also - shock horror - a General Medical Council legal assessor!

You could hear a pin drop as you listen for any further comment from lawyers on this case.

The only input as far as I can see, has been from Prof Sheila McLean from Glasgow in a BMJ blog and a concerned informal comment from a lawyer in Dr Grumble's blog. The word suicide was omitted from Prof McLean's account. I wonder if it was mentioned at all in Coroner Armstrong's summary. Was her death regarded legally as suicide or wasn't it?

WD- my understanding (and of course neither am I learned nor am I necessarily their friend), is that a narrative verdict is recorded when there is insufficient evidence to allow a more specific verdict. As a rule, verdicts seem to be mutually exclusive, and so if a narrative verdict is recorded then it is not a suicide verdict (or, more strictly, there was insufficient evidence to prove a suicide verdict - but then there is the option of an open verdict).

Wooltorton's inquest verdict was narrative.

Which seems - to Dr No - right off the wall. Putting aside the uncertainty about her clinical state, she did nonetheless (a) drink anti-freeze in lethal quantity, (b) pin a DNR note to her chest and (c) subsequently die from anti-freeze poisoning. If that isn't a suicide, what is?

But there is, just possibly, a bizarre twist to this. To record a verdict of suicide, there has to be evidence of intent. Apparently, just being "likely to be suicidal", and killing yourself by self-poisoning, is insufficient (and will result in an open or narrative verdict) - there has to be proof of intent eg a note.

Coroner Armstrong has form on this. Bizarre as it seems, could he have doubted in some subconscious way KW's intent - and so felt obliged to record a narrative verdict? If - a big if - that is true, then, by letting the doc's off the hook, he in effect said it was OK - because of the MCA - to let a woman die who did not at heart wish to die.

I think we have only just begun to scratch the surface on this one...

I think it could be said that far from entirely believing the evidence before him, the Coroner may have had a little doubt about the validity of the letter Ms. Wooltorton wrote, because as far as I can see, it was not witnessed (a requirement of the law in regard to Advance Directives) Otherwise he may not have had to resort to a narrative verdict.

I hope I haven't gone outside the present parameters of the argument, but it seems very odd that if the position taken by the Coroner as he was at pains to insist, was within the law, then why would he give a narrative verdict?

It seems to me Coroner Armstrong's behaviour gives rise to more questions than answers.

That said, I think the question of the AD's legal weight is not an issue, because the MCA was not in force at the material time; and furthermore, as an AD, it was over-ridden by the fact KW was said to be capacitous at the time of admission.

That said, it would seem to me that the AD (see here for full text) looked at in another way does bear more than a passing resemblance to a suicide note confirming intent.

And so we have a woman who (a) frequently says she wants to kill herself (b) takes steps to kill herself and (c) writes an AD which can more than pass muster as a suicide note showing intent - which must surely, on the basis of the facts (a) (b) and (c), be more than sufficient for a suicide verdict. But she got a narrative verdict...

The above paragraph should not be read to mean that I consider KW was permanently and resolutely determined to kill herself. My hunch - based on having seen many many similar patients - is that she had good days and bad, and on some of the bad days she was actively suicidal. A week later she may well have been not suicidal. She had a condition which in its name talks of emotional instability. It seems absurd and grotesque to stand by and let a person die in in the face of such whimsicality. Death, as we have said many times before, is a one way street, and it seems quite wrong to allow whim to decide passage down that road.

The case of an individual of sound mind who is resolutely determined to kill himself in, say, the face of an intolerable terminal illness is another matter. But KW's circumstances were not as such.

The bizarreness - the paradox - in KW's case is that Coroner Armstrong claims to have taken an exclusively legal route which, so far as I can see, could only lead to a suicide verdict; and yet he came up with a narrative verdict...

And the big unanswered question is: why?

When I read the Coroner's Verdicts on the soldiers killed in Afghanistan I rather wonder where this Coroner has come from! No investigation into whether her death was preventable, just a constant repetition of this being the "Law" a bit like the Snark of Lewis Carroll - say it three times (or more) and it must be right!?

This was not a question of Mental Capacity, it was a question of
Mental Health and with a narrative verdict, he was clearly unsure of what had gone on. This woman's condition was eminently suitable for a timely use of the Mental Health Act.

He had a duty to the deceased and failed her. The Doctors, for fear of a puerile possible prosecution for assaulting KW were encouraged to let her die from lawyers who did not think that this young woman's life was worth at least an-on-the spot Judicial decision. The lawyers were boxing above their weight as you say Dr No.

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