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News Inquests, Inquiries & Investigations 6th Jun 2024

Tim Green KC successful engaging A2 in inquest arising from shortcomings in the treatment of mental illness and subsequent emergency care.

At the recent inquest arising from LM’s death heard at Northampton Coroner’s Court, Tim Green KC established the presence of systemic failings in both the treatment of LM’s mental illness, and the emergency services response to that mental illness, had engaged A2 ECHR. This meant that the inquest had to consider the wider circumstances in which LM had died and enabled the Coroner to approach his conclusions with a critical eye to the conduct of other IPs. In coming to this judgment the Coroner took into account European and English appellate case law applying a restrictive application of A2 ECHR to health care related deaths, but nonetheless found for the family that A2 was engaged by the particular facts.

LM died as a result of suicide. He was being treated in the community by the NHS for his mental illness before he died. Accordingly, the Coroner returned a conclusion of suicide with a narrative including judgmental language in respect of the failings in the NHS care of LM, and the emergency services response to his suicide. The Coroner further found these shortcomings may have been causative of death.

Tim Green KC was instructed by Gary Rubin and Jo Kaucher of Blackfords Solicitors on behalf of the family.

The case has generated significant media interest. Please find BBC links here:

An alerter by Tim Green KC and Georgina Pein (pupil) following the case, considers the lessons learnt and the application of A2 ECHR to deaths in healthcare, read their alerter here.

Tim Green KC was short-listed for Health and Safety KC of the Year at the 2023 Bar Awards and was recently nominated as Legal 500 Corporate Crime KC of the year at the 2024 Legal 500 Bar Awards. He is recommended by Chambers UK and Legal 500 for his work in health safety, inquests & inquiries, environmental law, and financial work. His full CV can be found here.


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