Ferguson, Inquest into the Death of [2023] NICoroner 20 (11 December 2023)
The circumstances of Raychel Ferguson's death were the result of a series of individual human errors by healthcare staff, not a systemic or structural dysfunction of the type required to engage the enhanced investigative duty under Article 2 ECHR. The redress procedural obligation was satisfied by the inquest and prior civil settlements. No expanded verdict was required.
- Citation
- [2023] NICoroner 20
- Parties
- Deceased: Raychel Zara Ferguson; Next of Kin (no K): Raymond and Marie Ferguson; Interested Person: Western Health and Social Care Trust; Interested Persons (nurses): Nurse Noble, Nurse Gilchrist, Nurse McAuley, Nurse Roulston, Nurse Brice, Nurse Kirk
- Jurisdiction
- Northern Ireland
- Judgment Date
- 11 December 2023
- Procedural Posture
- Inquest / Verdict Following Inquest
- Outcome
- No enhanced investigative duty or expanded verdict required; inquest concluded with factual findings only.
- Legal Topics
- Article 2 ECHR, Medical Negligence, Systemic Failure, Hospital Governance, Expanded Verdict, Procedural Obligations, Hyponatraemia Related Death
Case Brief
Summary, issues, holding and outcome
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Parties
Raychel Zara Ferguson
Deceased
Raymond and Marie Ferguson
Next of Kin (no K)
Western Health and Social Care Trust
Interested Person
Nurse Noble, Nurse Gilchrist, Nurse McAuley, Nurse Roulston, Nurse Brice, Nurse Kirk
Interested Persons (nurses)
Procedural Posture
Inquest / Verdict Following Inquest
Legal Issues
- 1 Whether the enhanced investigative duty under Article 2 ECHR applies to Raychel Ferguson's death
- 2 Whether Raychel Ferguson's death resulted from systemic/structural dysfunction or individual/collective medical negligence
- 3 Whether an expanded verdict is required under Article 2 ECHR
Ratio Decidendi
The circumstances of Raychel Ferguson's death were the result of a series of individual human errors by healthcare staff, not a systemic or structural dysfunction of the type required to engage the enhanced investigative duty under Article 2 ECHR. The redress procedural obligation was satisfied by the inquest and prior civil settlements. No expanded verdict was required.
Court Disposition
No enhanced investigative duty or expanded verdict required; inquest concluded with factual findings only.
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