Adam Farrer

Viewing: Inquests, Public Inquires and Coronial Law for Adam Farrer

Adam specialises in Inquest work, Health and Safety and Personal Injury work. Adam’s Inquest and Health and Safety work consists of serious and complex cases. The majority of Adam’s Inquests Are Article 2 Inquests heard with Juries.
Adam is on the Attorney General’s Specialist HSE and Environmental Law Panel “A” List on the Attorney General’s Civil (Junior Counsel to the Crown) Panel. The Civil Panel encompasses Inquest and civil work on behalf of Government departments and includes personal injury work and judicial review work. Adam regularly appears for the Prison Service in death in custody Inquests.
Adam is listed in the Legal 500 (Regional Bar) as a Leading Junior for Inquests and Inquiries.
Adam is listed in the Chambers UK Bar Directory as a “Leader in their field” for health and safety work.
Adam finds that the Inquest work, Health and Safety and Personal Injury work compliment each other, with Adam regularly appearing at an Inquest and then acting in a subsequent Health and Safety prosecution and then the Personal Injury claim. Adam regularly defends Article 8 ECHR claims arising from deaths in custody and claims brought by prisoners.
Adam’s recent Inquest work has primarily involved acting for companies and large organisations, such as the Prison Service and Ministry of Defence. However, Adam has considerable experience of acting for families in a range of cases, such as death’s at work, road traffic accidents and deaths in Hospitals.
Golf, tennis and skiing.
Experienced in representing families and organisations in inquests.
Legal 500 2019
Notable Cases
Prison death Inquest – Leicester Coroner’s Court
October 2018
(2-week Article 2 Jury Inquest), acting for the Prison Service and Home Office in relation to a death by hanging of a 43-year-old Polish national prisoner. The deceased served a short sentence and was then released. He was recalled to prison for new offences within a week of his release. He was monitored under the ACCT system on two occasions due to relationship breakdown and deportation issues. He was served with notice of intention to deportation. Further, after the expiry of his sentence he was held in prison in immigration detention pending deportation. The Coroner accepted my submissions (on the basis of the Galbraith plus test) not to leave to the Jury any causative failings on the part of the Prison Service or Home Office. The Jury returned a conclusion of suicide, plus some criticisms of the NHS Trust in relation to healthcare.
Oxford Coroner’s Court
February 2018
6-day Article 2 Inquest, into the death of Justin Skrebowski, who was unlawfully killed whilst shopping in Poundland in Oxford by Trevor Joyce, a paranoid schizophrenic (with multi substance abuse issues). The killing was a completely random, unprovoked act. Mr Joyce pleaded guilty to manslaughter. Acted for Oxford Health NHS Trust, who had provided recent in-patient care and on-going care in the community to Mr Joyce. The Inquest closely examined the recent in-patient admission, the decision to discharge Mr Joyce, his risk to the public and the care he was provided with in the community during the weeks up to the killing. Mr Joyce had made previous threats to harm strangers. The Inquest heard evidence that Mr Joyce’s mental health deteriorated in the two months prior to the killing due to drug abuse, during which time his involvement with the Police and criminal justice system increased. The Coroner returned a conclusion of unlawful killing, together with a non-causative narrative conclusion, which found a number of failings by the NHS Trust which could have possibly (but not probably) contributed to the death.
Plymouth Coroner’s Court
October 2016
4-day Article 2 Jury Inquest, acting for UK Border Force, in relation to the death of a Dutch sailor. A Border Force Cutter Crew were tasked to search a lone yachtsman’s yacht at the quayside in St Mary’s, Scilly Isles. The yacht was had been towed into St Mary’s due to damage to its mast. The yacht was of interest to the Dutch Authorities due to travelling to Suriname. The sailor was co-operative with the Officers during their search for about 2 hours, then without warning he climbed the mast and jumped onto the quayside, dying almost instantly. Immediately prior to the incident the Officers had started to open the water tank. Subsequently Border Force Officers found 124 kilograms of cocaine worth approximately 20million. Jury/Article 2 Inquest due to the death occurring in circumstances where the deceased was dealing with Border Force Officers. Jury returned a conclusion of suicide.
Prison death Inquest – Ipswich Coroner’s Court
May 2016
(4-week Article 2 Jury Inquest), acting for the Prison Service in relation to a death by hanging of a 23-year-old prisoner. The deceased was serving an indeterminate sentence for public protection and was beyond his minimum tariff. He suffered mental health problems. The Inquest heard extensive evidence of his time in three different prisons over the last year of his life, including his risk of self-harm and previous incidents of self-harm. The Inquest also heard expert medical evidence in relation to mental health issues. The Jury returned a conclusion of suicide and did not find any relevant systemic failings.
Article 8(1) claim – Oxford County Court (sitting at HMP Woodhill) before HHJ Harris QC
March 2015
Acted for the Ministry of Justice in defence of a claim brought by Gary N, a category ‘A’ prisoner held in the Close Supervision Centre, serving life for double murder. HHJ Harris QC heard the case at HMP Woodhill in view of the claimant’s high-risk status. The Defendant admitted liability for breach of Article 8(1) ECHR arising from two breaches. The first related to the Prison wrongly opening and/or delaying in providing to the claimant (by 3 to 7 days) three items of legal mail (Prison Rule 39 mail). The claimant was awarded damages of 1,500, on the basis of 500 per Rule 39 letter. The second breach related to the failure to arrange an in-person visit between the claimant and his younger brother over a 14-month period. The claimant’s brother was also a long term serving prisoner. The claimant had not seen his brother for over 9 years. The claimant was awarded 2,000 for this breach. The claimant’s claims for aggravated and exemplary damages were rejected.
Prison death Inquest – Stourport on Severn Coroner’s Court
January 2015
(7-day Article 2 Jury Inquest), acting for the Prison Service in relation to a death by natural causes of a 43-year-old prisoner, who died from undiagnosed cancer. Healthcare staff believed the deceased had mechanical back problems. The Inquest heard extensive evidence from Healthcare staff (GP’s and nurses) in relation to the treatment given to the deceased in the last month of his life up to 36 hours prior to his death. The Inquest also heard expert evidence in relation to the appropriate standard of care from doctors and nursing staff.
HSE Inquest – Boston Coroner’s Court
October 2014
(4-day Article 2 Jury Inquest), arising from the death of a patient at Pilgrim Hospital whilst using an Encore standing aid hoist. Physiotherapy staff had removed a knee support from the device in an incorrect way, leaving a vertical post exposed (whereas the complete mechanism should have been removed). The patient collapsed and was impaled on the post by the rectum, resulting in his death. The Jury found that the death was as a result of a tragic accident that occurred as a result of the misuse of the Encore hoist, through a lack of adequate formal training.
Prison death Inquest – Stourport on Severn Coroner’s Court
October 2014
(7-day Article 2 Jury Inquest), acting for the Prison Service in relation to a self-inflicted death by a Polish prisoner in the segregation department in a high-security prison. The Inquest heard expert medical/psychiatric evidence and concentrated on the assessment by Prison and Healthcare staff on deceased’s level of risk to himself and on the systems relating to detention in the segregation unit of the high-security Prison.
Prison death Inquest – Leicester Coroner’s Court
September 2014
(4-day Article 2 Jury Inquest), acting for the Prison Service in relation to the self-inflicted death of a 21-year-old prisoner, with mental health problems. The Inquest heard expert medical/psychiatric evidence and concentrated on the assessment by Prison and Healthcare staff on deceased’s level of risk to himself.
HSE Inquest – Lincoln Coroner’s Court
March 2014
(8-day Article 2 Jury Inquest), case of a restraint death of a patient in a secure residential unit following an act of aggression by the patient. The case involved a substantial amount of eyewitness factual evidence, complex expert evidence in relation to restraint, asphyxia and pathology. Sensitive case in view of a restraint death of a mentally ill patient.
HSE Inquest – Boston Coroner’s Court
August 2013
(5-day, Article 2 Inquest), death of a patient arising from a fall from a window at Pilgrim Hospital. Legal argument in relation to whether the Inquest should be adjourned until after the HSE prosecution of the NHS Trust, arising from the failure to maintain the window restrictors. HM Coroner rejected the NHS Trust’s argument that the Inquest should be adjourned until the conclusion of the criminal proceedings. Expert evidence in relation to lack of maintenance of the window restrictors.
Inquest – Gloucester Coroner’s Court
January 2013
2-day Jury Inquest, acting for a site foreman (one of the interested parties) of a company that had resurfaced a road. The road surface mixture was defective resulting in the surface being extremely slippery when wet, which resulted in a fatal car crash. Expert evidence in relation to the motor car, the road surface/cause of the loss of grip and accident reconstruction evidence.
Inquest – East Sussex Coroner’s Court
May 2012
7-day Jury Inquest, acted for the MoD in relation to a friendly fire death of a British soldier in Afghanistan, who was mistaken for an insurgent and shot by a British sniper at night. Technical evidence in relation to the capabilities of night vision glasses.
Inquest – HSE; Nottingham Coroner’s Court
June 2011
8-day Inquest, acted for the HSE in relation to the death of a patient during an incident when he was restrained by Police Officers in Hospital. The patient became volatile and confused and locked himself in a shower room. Police Officers used force to extract him for the shower room, which ended in the patient’s death.
Inquest –Aberdare Coroner’s Court
January 2011
5-day Inquest, acted for the MOD in relation to the death of two teenage air cadets and two RAF pilots. The air cadets were on-air experience flights with the RAF in two Grob Tutor aircrafts. The aircrafts took off one after the other and sadly had a mid-air collision, resulting in the four deaths. The Inquest heard technical evidence in relation to the causes of the collision and lessons learnt in order to avoid a similar incident. I also acted for the MoD in relation to the fatal accident claims by the families of the air cadets.
Inquest – Trowbridge Coroner’s Court
April 2010
10-day Inquest, acted for the MOD in relation to the deaths of three soldiers arising from a friendly fire incident in Afghanistan, when a British forward air controller and a US weapon systems operator from a US F15 Strike Eagle Fighter made errors in relation to the co-ordinates for a 500lbs bomb drop location. This case involved sensitive public interest immunity issues in relation to secret US documents.
Recent Regulatory work:
HSE Prosecution of CP Environmental Limited, Derby Crown Court, HHJ Bennett
September 2018
defendant represented by a QC. Guilty plea on day of trial to a section 2(1) HSWA offence, following a serious injury involving a mobile crusher machine. An employee’s big toe and part of his second toe were amputated when caught in the teeth of the machine when he operated it with the remote-control unit whilst he performed maintenance on it. A number of employees had devised an unsafe system of performing maintenance work on the crusher machine whilst it was powered and operated it via the remote-control unit. This was done as a shortcut to save time. They should have isolated the power during maintenance work, which would have prevented the use of the remote-control unit and such an accident occurring. The defendant company accepted it failed to supervise and monitor the employees work adequately. Small/micro company, medium culpability, level 3 harm. Fine of 34,000, plus full costs.
HSE Prosecution of IKO Design Limited, Leicester Crown Court, HHJ Brown
January 2018
Guilty plea to work at height offences, following the death of an employee, who fell through a fragile roof at the defendant’s factory whilst assisting another employee to cut a hole in the roof for a chimney vent. The defendant took no steps in relation to safety. There was no risk assessment, safe system of work, safety equipment or training. High culpability and likelihood of harm found. A major issue arose as to the defendant’s financial disclosure, resulting in Financial Circumstances Orders and the instruction of a forensic accountant. This resulted in the defendant accepting its turnover was substantially in excess of the figures shown in its post-accident accounts and the Judge ignoring the latest accounts (showing a turnover of 21,000). Sentenced on the basis of a turnover of 212,000. Fine starting point of 240,000, reduced to 160,000 for mitigation and further reduced to 100,000 (on the basis of proportionality/means) plus costs.
Defence to an Environment Agency Prosecution of two partners in a farm business – Hereford Magistrates Court
November 2017
An employee of the farm omitted to close a valve on the irrigation system, which resulted in 100’s of tonnes of digestate (fertilizer) being accidentally discharged onto a field and then into the River Leadon. The fertilizer affected 19 kilometres of the river and was estimated to have killer over 15,000 fish. Guilty plea on the basis that the discharge was ‘negligent’. The partners were fined 5,500 each, plus costs.
Defence to a HSE Prosecution of a director (in his personal capacity for consent/neglect, section 37 HSWA) – Shrewsbury Crown Court
October 2017
The defendant was a builder contracted by a farmer to build a barn. The barn was located under high voltage power cables. The defendant’s cousin was working with him on the roof of the barn. He walked into the power cable and was killed. The farmer was also prosecuted (under the CDM Regulations) as the designer of the barn. Guilty pleas entered to section 3(1) offences relating to the risk of the power cables and work at height (no edge protection etc). Sentenced on the basis of high culpability. Sentenced to 6 months’ imprisonment suspended for 2 years, plus 200 hours’ unpaid work.
HSE Prosecution of Anixter Limited, Birmingham Crown Court, HHJ Henderson
October 2017
Guilty plea (indicated a few days prior to the trial) to a section 2(1) HSWA offence, where an employee sustained serious injuries (intensive care for 5 days) when he was crushed by a 1.5 tonne drum of steel cable as he attempted single-handed to roll it down a ramp from the scales of a coil machine. He lost control of the drum and it rolled over him. The defendant accepted its system of work was unsafe. The Judge found that the harm risked of level ‘A’ (death or very serious injury), culpability and likelihood of harm risked were both found to be between medium and low. Sentence imposed was a fine of 170,000 (15% credit for plea allowed) plus costs.
HSE Prosecution of Landowner Limited, Birmingham Crown Court, HHJ Laird QC
September 2017
2-week trial, defendant pleaded guilty to a section 3(1) HSWA offence at the close of prosecution case after a submission of no case to answer failed. Defendant was developing a former industrial building into houses and offices. Fatal accident, when a painter fell from unsafe scaffolding. The defendant failed in its duty as the managing contractor to manage the site and scaffolding safely and the Judge found there was an element of cost cutting. Defendant was a micro company. Fine of 40,000 plus costs.
HSE Prosecution of United Lincolnshire Hospitals NHS Trust – Lincoln Crown Court, HHJ Heath
July 2017
3-week trial, defence represented by a QC and junior. 1 million fine imposed. The Trust was convicted of an offence contrary to section 3(1) HSWA arising from a fatal accident involving a patient. Physiotherapy staff were working with the patient using an Arjo Encore Standing Aid Hoist to increase his mobility. Staff incorrectly used the machine, by removing the knee pad leaving a vertical metal post in place. The patient collapsed and fell onto the exposed metal post. The post penetrated his rectum, causing catastrophic internal injuries resulting in his death later that day. HHJ Heath found that the unsafe system was widespread and longstanding and the danger created by leaving the vertical post exposed was and should have been obvious. HHJ Heath found that the Trust’s culpability for the unsafe system was high. HHJ Heath found that the starting point for the financial penalty was 2.4million. However, given that a fine would affect its ability to perform its services to the public he reduced the fine to 1million, plus costs.
Defence to a HSE Prosecution of a partnership that owned a farm – Stafford Crown Court
March 2017
a 64-year-old farm manager was killed when he fell through a fragile roof of a barn he was in the process of dismantling. Guilty pleas by the partnership and case committed to the Crown Court for sentence. The prosecution contended for very high culpability. HHJ Chambers found culpability as high, with medium likelihood of harm and after making an allowance for positive mitigation imposed a fine of 60,000 plus costs.
HSE Prosecution of Northumbria University – Newcastle Crown Court, HHJ Bindloss
January 2017
two second year Applied Sport Science students at the University volunteered during a class to take part in a practical exercise designed to measure the effects of caffeine on the body during exercise. The two students should have been given of 0.30grams and 0.32grams of caffeine respectively. However, due to errors in calculating the dose of caffeine made by the laboratory technicians, the two students were erroneously given some 30.7grams and 32grams of caffeine respectively. This was 100 times the correct dosage and almost double a potentially fatal dose. The two students suffered violent side effects within minutes of drinking the solution and required hospital treatment, including spending a number of days in intensive care and suffered life-threatening reactions. Guilty plea to a section 3(1) HSWA offence. HHJ Bindloss found the University was highly culpable, with a medium likelihood of level ‘A’ harm occurring, as a result of it not having in place any risk assessment for the caffeine exercise, failing to have a system to check the dose and failing to adequately train its staff. A fine in the sum of 400,000 (plus costs) was imposed.
HSE Prosecution of Waltopia (a Bulgarian company) – Derby Crown Court
December 2016
The company pleaded guilty to an offence contrary to regulation 4 (1) of the Work at Height Regulations 2005 and was fined 500,000 by the District Judge. The company appealed to the Crown Court. The appeal was rejected. The offence concerned unsafe work at height practices by employees whilst erecting an outdoor climbing facility. Employees were seen being lifted on a pallet on the forks of a telehandler. A member of the public reported the unsafe practice to the company. However, despite the warning the unsafe practice was repeated. A HSE Inspector subsequently attended and witnessed a number of employees working at height on a roof without any safety measures and climbing from the basket of a cherry picker onto the roof. The Court found the company to be highly culpable, with a high likelihood of level ‘A’ harm occurring.
HSE Prosecution of an alcohol and chemical distribution company - Wolverhampton Crown Court, HHJ Burbidge QC
August 2016
explosion and significant fire, when static electricity ignited vapour from ethyl acetate that was being filled into an IBC via a mobile dispensing unit. An employee received burn injuries. The fire spread rapidly, destroying the three-story warehouse and causing damage to cars and houses outside the defendant’s premises. The fire burnt for 18 hours before being extinguished by the Fire Service. The defendant pleaded guilty to section 2(1) and 3(1) HSWA offences and was fined 270,000, plus costs. Culpability was assessed as medium harm category 1, with high likelihood of harm and seriousness of harm as ‘A’. Failings included failing to ensure employees earthed the IBC in order to guard against the risk of static electricity igniting the vapour from the chemical, filling the IBC in a non-contained area and running a flexible hose through an open fire door in the Warehouse, which caused the rapid spread of the fire into the Warehouse containing a large quantity of chemicals.
HSE Prosecution of a roofing company (the principal contractor) and a crane lifting company - Northampton Crown Court, HHJ Mayo
June 2016
fatal fall through a skylight on a fragile roof. Both defendants pleaded guilty on the first day of the trial. The deceased worked for the crane company and was engaged in lifting roof sheets onto the fragile roof, without any safety equipment, such as roof boards. The crane company pleaded to a section 2(1) offence and was fined 83,300 plus costs and the principal contractor pleaded guilty to a section 3(1) offence and was fined 104,250 plus costs. The principal contractor failed to inform the crane company of the lack of safety measures on the roof and the crane company failed to perform an adequate survey of the fragile roof.
HSE Prosecution of a transport company – Derby Crown Court
May 2016
Fatal crushing incident when an employee was crushed as he refuelled his lorry by another employee reversing a tipper lorry. Judge found high culpability and a high likelihood of harm. The defendant entered a guilty plea to a section 2(1) HSWA offence. The Judge rejected the defence argument that the 2016 Definitive Guideline should not apply to the case – based on the delay in the prosecution, which was caused by the Coroner’s delay holding the Inquest. Fine 300,000, plus costs of 50,000 (including the HSE’s Inquest costs). The defendant’s application for permission to appeal (opposed by the prosecution) was refused by the single Judge and then abandoned by the defendant shortly before the oral permission hearing.