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Legal case

Striking the balance — the risks of pre-inquest admissions

How trusts should exercise caution when making pre-inquest admissions


This update explores the circumstances and potential consequences of the recent High Court case of Somoye v North West Anglia NHS Foundation Trust [2023] relating to a claim which followed an inquest hearing. In that case, an NHS Trust made pre-inquest admissions based on evidence that was changed during the course of the inquest, but were not allowed to withdraw or change those admissions accordingly. This update explores how trusts should exercise caution when making such admissions whilst exploring the potential costs and benefits of this approach.  

Facts of the case

Dr Oluyinka O Somoye attended the North West Anglia NHS Trust Hospital on 28 February 2018 for a myomectomy. She was discharged on 3 March. She later suffered a seizure at home and returned to the hospital where she was re-admitted at 04:15 on 7 March after suffering from severe abdominal pain and feeling unwell. She underwent an x-ray at 06:51. However, at 13:00 she collapsed and suffered cardiac arrest. Resuscitation was unsuccessful and she was pronounced dead at 14:52 on 7 March 2018.

A post-mortem was undertaken on 12 April 2018 by Dr Penny Wright (Pathologist) and gave the following cause of death:

1a Multiorgan failure

1b Abdominal sepsis

1c Small bowel ileus

2 Uterine myomectomy


North West Anglia NHS Foundation Trust undertook a Serious Incident Investigation in July 2018 which identified several issues with their care. An external report also found that care was below an acceptable standard.

An inquest was listed and the coroner requested expert evidence from Professor Winslet (colorectal surgeon). In his report dated 17 December 2018, Professor Winslet was of the view that the deceased had aspirated causing cardiac arrest. He said that if the court were satisfied that the bowel was not the cause of this, then it could have been treated with nasogastric decompression which could have avoided death. This was supported in an advice letter in March 2019, and on this basis, the trust made pre-inquest admissions. The admissions were later reiterated again.

In cases such as this, admissions of liability pre-inquest can be an important mechanism to a defendant trust in various ways. Admissions may take the sting out of an inquest for the following reasons:

  • Admissions can have an effect on the recoverability of a family’s inquest costs during any subsequent litigation. The costs of an inquest including representation may not be recoverable where liability is no longer an issue. To minimise the risk of paying the costs of an inquest, a defendant must make clear any admissions of liability and those admissions must be sufficient to prevent any further need for liability to be explored.
  • They may also reduce or restrict claimant’s costs in investigating a civil claim pre-action if all avenues do not need to be investigated. Full admissions would allow the parties to focus on exploring an award of damages instead to keep matters swiftly moving and thus, saving costs and time for both parties.
  • Admissions can reduce or prevent additional distress for a family knowing the defendant has been open from the outset.
  • Admissions may save court time if the parties can reduce the witnesses required at the hearing, given they are no longer required to discuss areas where admissions have already been made. Therefore, the overall length of the hearing may then be reduced.

Inquest hearing

However, on 11 June 2021, Dr Wright (pathologist) disputed Professor Winslet’s report and said that her view was that the cardiac arrest was instead caused by hyperkalaemia caused by multi organ failure. Therefore, nasogastric decompression would not have prevented the death and the trust was not at fault.

Professor Winslet then changed his opinion entirely. This was because the deceased would only have survived if the source of the sepsis could have been controlled surgically. The whole of the bowel was said to be abnormal and surgery could not have corrected this. As such, Professor Winslet could not say definitively what had caused the cardiac arrest and the inquest was adjourned so that further questions could be put to the pathologist. After further questioning, the coroner found that it was not possible to say whether aspiration led to cardiac arrest or whether cardiac arrest had caused the aspiration.

As a result, the coroner determined that they could not, on the balance of probabilities, say whether further treatment would have changed the eventual outcome.

The defendant's application

The defendant subsequently put the claimant on notice in March 2022 that they were commissioning their own expert evidence on causation, given Professor Winslet’s change in opinion. The claimant issued proceedings four months later which were served on 11 July 2022 along with an application for judgment based on the pre-inquest admissions.

In light of the new evidence obtained, the defendant made an application on 13 July 2022 to resile from the causation admissions only. As part of the application, the judge considered the legal test for withdrawal of admissions under Practice Direction 14, paragraph 7.2 and the key criteria were discussed as follows:

  • Grounds upon which the applicant seeks to withdraw the admission including whether new evidence has come to light which was not available at the time the admission was made. It was acknowledged that Professor Winslet had changed his mind, but that he had in fact previously raised two theories as to the cause of death at the time the admissions were made. Thus, it was already a theory that had a clear possibility, and it was deemed the defendant’s experts’ reports were not new evidence.
  • Conduct of the parties including conduct which led the party making the admission to do so. It was said that a significant delay had been caused and Master Sullivan criticised the defendant’s conduct.
  • The prejudice that may be caused to any person if the admission is withdrawn.
  • The prejudice that may be caused to any person if the application is refused. Master Sullivan recognised that the claimant had proceeded to inquest with limited evidence, including no factual evidence given the admissions made. There was a missed opportunity to obtain factual evidence closer to the incident and the claimant had incurred costs investigating quantum which may not have been warranted when liability remained ‘up in the air’. She accepted that distress and prejudice would be caused if the application were successful. She concluded that whilst the defendant would not be able to dispute liability, it would be mitigated by the fact the extent of losses could still be challenged.
  • The stage in the proceedings at which the application to withdraw is made, in particular in relation to the date or period fixed for trial. The application had been made early in proceedings, but this carried little weight given the time that had passed since the incident and the admission, and that there had already been a fact-finding inquest.
  • The prospects of success (if the admission is withdrawn) of the claim or part of the claim in relation to which the admission was made. Master Sullivan considered that the defendant did have a real prospect of success with their causation arguments in respect of allegations from 7 March based on the evidence, but there was no evidence available dealing with causation of the earlier substandard treatment on 3 March. Though Professor Winslet indicated that the earlier substandard treatment was not causative, and this evidence pre-dated the defendant’s repetition of the admission, so it must have been considered by the time the admission was made. 
  • The interests of the administration of justice. Master Sullivan allowed judgment on liability, but with damages to still be assessed. Arguments on the extent of the injury, life expectancy, and loss could still be made providing they did not raise an argument inconsistent with some injury (including death) having been caused by the negligence. This would not cause any difficulty with the administration of justice.


Whilst the function of an inquest and a civil claim have different purposes, the effects of pre-action admissions can have a detrimental effect on any future civil ligation as outlined in this case.

The inquest process itself is a fact-finding investigation and allows for a death to be correctly recorded and registered. The narrative verdict at an inquest is not admissible evidence for the purpose of civil proceedings but pre-inquest admissions are binding.

It is a delicate balance for defendants in looking to reduce costs but also ensuring there is no prejudice to their future position, so on the face of it, this judgment would seem harsh. One could argue, as the defendant NHS trust did, that they should have been able to change their own admissions in line with the evidence. However, the court has exercised caution given the precedent this would set and the effect it would have on future civil litigation. This case is significant and we suggest that the practical learning that can be taken from it includes the following:

  • When considering pre-inquest admissions, consider whether to obtain independent expert evidence rather than relying on the coroner’s expert. This will allow the defendant trust to explore in detail the issues raised.
  • Where an application to resile from an admission is to be made, it should be done as quickly as possible. We do not know or comment on the reasons but note that the inquest concluded in June 2021 and the defendant advised the claimant in March 2022 that they were intending to seek independent expert evidence and the application to resile was made in July 2022.

Defendants will still be encouraged to make pre-inquest admissions given the potential cost and other benefits, and thus, any advice is simply to be cautious when making pre-inquest admissions and aware of the level of permanence that comes with them.

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