Saturday, September 16, 2006


UNCOVERING
THE TRUTH ABOUT
DR DAVID KELLY’S DEATH

The Kelly Investigation Group (KIG) is a loose affiliation of professionals and laypeople from all walks of life; it includes nine doctors, four of them surgeons, and a QC. Medical and legal expertise has ensured our objections to the the official line on Dr David Kelly’s death are taken seriously by the media and public, even if the authorities affect to ignore them. Our aim is to ensure agents of the state do not bury the truth, along with Dr Kelly.

SUSPICIONS FROM THE START

During 2002/3 it was obvious to many that the search for WMD in Iraq was a disingenuous ploy to secure regime change. Blair and his aides had claimed that it would take only 45 minutes for Saddam to launch a CBW attack on British bases, and that mobile laboratories found in Iraq were for the purpose of making chemical/biological weapons. In asides to journalists Dr David Kelly had shot both assertions down in flames. So when he was found ‘dead in the woods’ three days after being hauled before a televised government committee, many of us were highly suspicious.

Why were Thames Valley police labelling Dr Kelly’s death a ’suicide’ before his body had been examined? At the age of 72, judge and law lord Brian Hutton had never before chaired a public inquiry - so why did the prime minister’s old friend Charles Falconer appoint this safe establishment figure at such extraordinary speed*?

As the Hutton Inquiry got underway in August 2003, I pored over the transcripts in an attempt to understand exactly how Dr Kelly had died. I listed aspects of the case that did not add up, and joined an internet forum to correspond with others working in a similar vein. One was IT expert Garrett Cooke.

INITIAL PLEA TO THE CORONER

On 20th November 2003 Garrett and I wrote a letter to coroner Nicholas Gardiner explaining our concern that the inquest had been subsumed into the Hutton Inquiry. In particular, we listed the reasons why we felt a full inquest with powers to subpoena witnesses and hear evidence under oath should be held:
  • Dr Kelly’s body appeared to have been moved - twice
  • the knife, bottle of water, glasses, and cap reported beside the body by later witnesses, were not seen by the two volunteer searchers who first discovered it
  • DC Coe was with the body at the time its position changed from sitting to lying
  • DC Coe claimed he was with one other officer yet five witnesses said he was with two
  • the primary cause of death was given as haemorrhage from an incised wound to his left wrist, yet the amount of blood at the scene was, according to the paramedics, extremely sparse
  • vomit stains from the corners of his mouth to his ears suggested Dr Kelly had died on his back, yet his position when found was slumped against a tree
  • the puzzling nature of the wound: the severing of a single artery deeply embedded in the left wrist and total avoidance of the more superficial radial artery
    We received no response.

‘SECTION 17A’ MISAPPLIED

Later we discovered that to avoid an inquest, Lord Chancellor Charles Falconer had invoked Section 17a of the Coroner’s Act of 1988, citing as his reason avoidance of duplication (having both an inquest and an inquiry) and consequent distress to the Kelly family.

However, Section 17a was introduced in 1999 at his instigation to avoid unnecessary repetition (and mounting costs) in cases of multiple deaths with a single known cause, e.g. a train crash or a ferry disaster; Dr Kelly’s was a single, high profile death of unknown cause. In view of the political manoeuvres preceding this high-profile death, one suspects the avoidance of ‘distress’ to the family was a very British excuse masking the real reason: that the authorities did not want witnesses subpoenaed and giving evidence on oath.

Had the scientist’s close female friends, Mai Pederson, Gabriele Kraatz Wadsack and Judith Miller been subpoenaed we might have been provided with a much more intimate portrait of events leading up to his death.

BUILDING A MEDICAL CASE

Faced with the Coroner’s wall of silence, I decided to try to secure medical support. I started a blog listing a number of KIG concerns and wrote two articles for the internet entitled - ‘Dark Actors at the Scene of Dr Kelly’s Death’ (October 2003) and ‘The David Kelly Story: Turning Murder into Suicide‘ (28 November 2003.) The latter was a critique of the forensic pathologist’s evidence to the Hutton Inquiry; for to me, his reasoning seemed in places, quite farcical.

On 29 November 2003 Dr Searle Sennett, a specialist in anaesthesiology from Johannesburg, responded to these articles by e-mail as follows:

Dear Rowena

I have just read your piece at rense.com and also the one at propaganda matrix.com and I complement you on both of these articles but, more importantly, on your guts and preparedness to take on the Establishment. I am a retired specialist anaesthetist and I too, without knowing the details of the Kelly incident that you do, considered the whole “suicide” story to be phoney in the extreme. I am quite satisfied that cutting the ulnar artery in the manner described could not have been fatal.

He was clearly murdered in some other manner and, in my opinion, there are a variety of ways in which it could have been done.

You did mention the use of a chloroform-like substance, of which there are many, and I can assure you that the modern volatile anaesthetic agents are extremely potent. They would not necessarily kill but could certainly cause unconsciousness in less than a minute especially if applied in high concentration. The subject could then be asphyxiated by means of a plastic bag over his head which, in fact, could also contain the agent. To show this technique is distinctly feasible, I mention the incident where a potent anaesthetic agent was introduced into the air-conditioning system of a Moscow theatre and which incapacitated and, indeed, killed the Chechen terrorists and some of their hostages.

Injectible muscle relaxants paralyse all muscles within seconds and stop the breathing of the subject receiving them. Although normally intravenous, the injection could, in fact, be given into any muscle or even under the hair of the scalp, or elsewhere, so as to avoid subsequent detection. Muscle relaxants are part of the lethal cocktail injection used in many US prisons to carry out the death sentence.

It will be very interesting to see what approach Lord Hutton takes concerning the inquest and whether he, too, attempts to cover up the obvious murder. Meanwhile, I am not surprised that Tony Blair is suffering from a variety of stress-related disorders!

Keep up the good work.

Your sincerely
Searle Sennett
Johannesburg

Anomalies continued to accumulate, but things were set alight when a friend sent me a letter published on 15 December 2003 in the Morning Star from orthopaedic and trauma surgeon, David Halpin. Here was a surgeon, a man with intimate knowledge of arteries, and how they behave, saying he did not see how Dr Kelly could have died of haemorrhage from transection of a single ulnar artery:

Morning Star letters 15-12-03

I write to enquire as to the status of the Coroner's inquest into thedeath of Dr David Kelly. I hope that it has not been subsumed within the Hutton enquiry.

He had been put through the psychological mincing machine of the elite running this country and it is easy to imagine his sense of failure aswell as betrayal in both directions.

We have been told that he died from a cut wrist and that he had non-lethal levels of an analgesic in his blood. As a past trauma and orthopaedic surgeon I cannot easily accept that even the deepest cut into one wrist would cause such exsanguination that death resulted. The two arteries are of matchstick size and would havequickly shut down and clotted.

Furthermore we have a man who was expert in lethal substances and who apparently chose a most uncertain method of suicide.

The picture fits more with 'a cry for help' [comment by DH - as seen in survivors in A&E departments].

I have hesitated in writing this because I would not wish to hurt any family feelings but the elite have shown no such qualms. I am pleased to note that even the BBC speaks of his 'alleged' suicide.

David Halpin FRCS

The point that David Halpin raises is key: the primary cause of death could not have been haemorrhage because it is virtually impossible to bleed to death from severing a single ulnar artery. Over the ensuing weeks we honed and refined our case to include arguments against the second and third causes of death cited - poisoning by co-proxamol and atherosclerosis. With Dr Sennett and David Halpin’s continued input and support, the KIG was able to develop a strong medical case against suicide.

Around this time we were joined by Jim Rarey, an ex-newspaper editor from the US, who wrote seven articles for the internet on a number of aspects of Dr Kelly’s death.

KELLY’S DEATH A PHENOMENON ACCORDING TO STATISTICS

In January 2004 we were contacted by Dr Andrew Rouse, Senior Lecturer in Public Health and Dr Yaser Adi, from the Dept of Public Health & Epidemiology at the University of Birmingham, who three months earlier had submitted a letter to national newspapers:

IS DR KELLY A STATISTIC OR A PHENOMENON?

The pathologist who performed Dr Kelly’s autopsy reported that “The features… of Dr Kelly’s wounds… were quite typical of self-inflicted illness”. Unfortunately he did not report that it is almost unheard of for such wounds to result in death.

Suicide associated with wrist-slashing is extremely rare - so rare that the Office of National Statistics does not report wrist slashing as a specific cause of death; it groups such deaths with other uncommon suicide methods such as belly and abdomen stabbings and throat cuttings (see table)

This table shows that fewer than five 55-50 year old men use cutting and piercing instruments to commit suicide annually. This statistical evidence, combined with the fact that even after searching the medical literature and speaking to medical and surgical colleagues we have not been able to document that wrist slashing can lead to successful suicide, suggests that for all practical purposes wrist slashing suicide does not exist in Britain.

Suicide and self inflicted injury by cutting and piercing instruments amongst males in England and Wales

Year 50-54 55-59 60-64 65-69
1991 2 4 9 8
1992 5 6 4 1
1993 7 4 6 4
1994 2 3 3 6
1995 6 5 3 5
1996 6 4 4 5
1997 8 4 3 1
1998 7 7 2 8
1999 5 4 5 3
2000 9 3 2 4
Av 5.5 4.4 4.1 4.5

Data from: Twentieth Century Mortality, Office of National Statistics, London 2003

We must also remember that Dr Kelly was a first rate researcher. As such, before making a suicide attempt, he would surely have done an internet or library search into the success of various suicide methods. He would have learnt that - since it invariably fails - wrist slashing is not a recommended suicide method. There fore why would Dr Kelly slash his wrist in the first place and against, all odds, actually die?

MORE DOCTORS CHALLENGE OFFICIAL SUICIDE RULING

As the medical case challenging suicide became stronger, we were happy to welcome in a new doctor - Chris Burns-Cox, and two more surgeons - Martin Birnstingl and William McQuillan. Birnstingl, a retired specialist in vascular surgery from London responded enthusiastically to a Kelly article with “Count me in”. He was a foundation member of the Vascular Surgical Association of GB and Ireland and President in 1986. In private e-mails he wrote:

Vascular surgeons deal with vessels of all sizes but I have never seen or heard of anybody dying from a cut wrist artery even when both ulnar and redial have been cut

Dr Kelly did not “slit his wrists” as suggested by Professor Milroy. The evidence is that one wrist was cut, dividing only one of the four main wrist arteries, which is very unlikely to have been fatal.

During 2004 I made contact with a Dr C Stephen Frost who had written a list of 35 questions about Dr Kelly’s death on the Independent internet forum . Working together, and liaising with the rest of the medico-legal team, we managed to get six letters published in the Guardian:

1. OUR DOUBTS ABOUT DR KELLY’S SUICIDE 27 January 2004 signed by David Halpin, C Stephen Frost, Searle Sennett

2. MEDICAL EVIDENCE DOES NOT SUPPORT SUICIDE BY KELLY 12 February 2004 signed by Andrew Rouse, Searle Sennett, David Halpin, C Stephen Frost, Peter Fletcher, Martin Birnstingl

Our arguments met with a blustering emotional response from Professor Chris Milroy in a letter entitled: FANTASISTS & DR KELLY14 February 2004

5. QUESTIONS STILL UNANSWERED OVER DR KELLY’S DEATH 19 February 2004 signed by Andrew Rouse, Searle Sennett, David Halpin, C Stephen Frost, Peter Fletcher, Martin Birnstingl

4. NEW DOUBTS OVER KELLY 28 September 2004 signed by C Stephen Frost, David Halpin, William McQuillan, Searle Sennett

5. QUESTIONS OVER KELLY 28 December 2004 signed by Dr Michael Powers QC, Martin Birnstingl, Chris Burns-Cox, C Stephen Frost, David Halpin, William McQuillan, Andrew Rouse, John Henry Scurr, Searle Sennett

6. RE-OPEN THE INQUEST INTO KELLY'S DEATH 15 March 2004 signed by C Stephen Frost

The first letter, published on 27 January to coincide with the publication of the Hutton Report, caused a media storm, and we were inundated with requests for radio and TV appearances. David Halpin appeared on TV and radio in the UK, and Dr Sennett gave newspaper interviews from his home in Johannesburg. The Evening Standard ran a headline on the evening prior to the publication of the Hutton Report: “Was Kelly Murdered?” But since ‘The Sun’ chose to leak the Hutton Report a day ahead of publication - and we think this may have been a deliberate tactic - the angle of possible murder was not pursued in the media the following day.

On 21 January 2004 five of us - David Halpin, Dr Searle Sennett, Dr C Stephen Frost, Garrett Cooke and myself - wrote an eleven-page letter to the Coroner setting out our concerns in detail. He failed to respond. A month later I phoned him to ask if he had received the letter - he said he had noted the contents but did not think these were sufficient grounds for concern. He had seen a police report and was satisfied everything was in order.

On 31 January highly qualified pathologist Dr Peter Fletcher wrote a letter to the Daily Telegraph:

Sir,

As a retired pathologist, I have been dismayed by the lack of information on the precise circumstances of the discovery of Dr David Kelly’s body. It is claimed that the major cause of death was blood loss from a severed wrist artery, possibly complicated by the ingestion of an unstated number of co-proximal tablets. An adult human body contains about 10 pints of blood, of which about half has to be lost to cause death. Anybody who has seen five pints of blood spurted forcefully out of a severed artery will know that there is one hell of a mess. The two searchers who found the body did not even notice that Kelly had incised his wrist with a knife. The two paramedics who arrived at the scene later apparently stated that there was remarkably little blood around the body.

Something, somewhere is seriously wrong. Either Dr Kelly did not die of blood loss or it occurred at some place distant from where the body was found. It is, of course, possible that blood was spattered everywhere, which four witnesses failed to notice.
A coroner has the power of subpoena, witnesses give testimony under oath and a jury is usually involved. Lord Hutton was denied these requirements for his inquiry.

Dr A Peter Fletcher, Pathologist, Halstead, Essex

I contacted him and he too agreed to lend his support to the KIG.

I was put in touch with lawyer Michael Shrimpton by an e-mail correspondent and he joined the cause on 29 January 2004. The following month he was invited onto the Alex Jones Show, one of the top conspiracy radio programmes in the US. Unfortunately the slant he put on Kelly’s death - that it was a ‘hit’ performed by the French DGSE - was not one shared by the rest of the KIG; although allegedly received from intelligence sources, there was no way of corroborating it. We were frankly uneasy with his strong bias towards the US’s ‘neocon’ administration.

On 8 February 2004 Andrew Rouse and Yaser Adi submitted an adapted version of their original letter entitled ‘Hutton, Kelly and the missing Epidemiology’’to the British Medical Journal. They called for readers to send in details of any 55-65 year old males who had committed suicide by slashing their wrist, during the previous 10 years.

Professor Milroy responded to their report by saying, 'The problem with use of statistics in any single case is that unlikely does not make it impossible.’ In his view the combination of all three causes on the death certificate was sufficient to account for Dr Kelly’s death. This had been the key tactic of KIG opponents: not to examine one cause of death at a time, but if one cause did not stand up, hop on to the next one, or even cite all three as ’somehow’ working together -- hardly a scientific way to proceed.

Another surgeon - John Scurr - was quoted in a Washington Post report, 21 February 2004.
I looked up his details and found him to be a practising vascular surgeon, also London-based. David Halpin wrote to him and he too become a willing participant in the KIG. He has since appeared on Channel 4 News and in a US documentary to be screened in 2007 - in both cases explaining in his professional capacity why Dr Kelly is highly unlikely to have bled to death from a single transected ulnar artery. He put us on to his friend and lawyer, QC Michael Powers. Once he had reviewed all evidence accumulated by the KIG, it was his view that there should have been a full inquest into Dr Kelly’s death.

On 29 February 2004 Renan Talieva, an e-mail correspondent from the US, wrote a long and detailed article derived from KIG discussions and her own assiduous research entitled “The Strange Suicide of David Kelly.”

CORONER SHUTS THE DOOR

Before the Coroner returned to court after reviewing The Hutton Report, a letter from Michael Powers was published by ‘The Times’ declaring:

Suicide cannot be presumed. Even evidence pointing to the likelihood that Dr Kelly took his own life is not sufficient. Suicide has to be proved beyond reasonable doubt.

After reviewing the Hutton Report, coroner Nicholas Gardiner returned to court on 16th March 2004 to announce his decision on whether to re-open the inquest into Dr Kelly’s death.
The same day David Halpin was interviewed by the Today programme, and when Gardiner declared his satisfaction with the Hutton Inquiry‘s ruling of suicide, was asked to comment.
Around this time, practising vascular surgeon John Scurr and QC Michael Powers made separate appearances on Channel 4 News. Mr Scurr explained why, in his view, one cannot bleed to death from full transection of a single ulnar artery while Michael Powers stated that by law, suicide must be proved beyond reasonable doubt, and an inquest was the only forum equipped to provide this degree of rigour. In his view the medical evidence provided since the Hutton Inquiry was sufficient to warrant a full inquest. When phoned by the Channel 4 News team, Dr Nicholas Hunt, the forensic pathologist to the Hutton Inquiry, said that he too would be ‘more comfortable’ with a full inquest.

On 13 May 2004 Renan Talieva answered the Coroner’s refusal to reopen the inquest with an excellent and thoroughly researched critique of the coroner’s actions in “The Coroner and David Kelly”.

In response to the KIG’s medical arguments, Professor Robert Forrest, forensic toxicologist at Sheffield University, set up the ‘International Toxicology Advisory Group’ and on 18 September 2004 had an article published in the BMJ entitled ‘Forensic science in the dock’. The Hutton Inquiry had conveyed the impression that Dr Kelly may indeed have taken the 29 tablets missing from the blister packs in his pocket, even though the toxicologist stated that the amount he measured was only a third a what is normally a fatal amount. But in this article Forrest et al listed reasons why forensic science was unable to specify the amount of drug a person had taken prior to their death.

“Post-mortem measurements of drug concentration in blood have scant meaning except in the context of medical history, the sequence and circumstances surrounding death, and necropsy findings. The paucity of evidence based science, coupled with the pretence that such science exists in regard to post-mortem toxicology, leads to the abuse of process…’

In December 2004, in a 'Daily Mail' article entitled ‘Specialists demand a new Kelly inquiry’ it was reported that medical and legal experts in the KIG were arguing that it was vital to have an inquest. Michael Powers called for backers to help him fund a legal challenge against the coroner’s decision not to reopen the inquest. It was discovered however, that without a ‘properly interested person’ to call for a judicial review of the coroner’s decision, the KIG could not proceed.

A ‘properly interested person’ is a legal term for what in Coroner’s Law has to be someone who stands to gain or lose by the death in question. In practise, that could only have been Mrs Kelly, and she made it clear in a private phone call that she did not want the inquest re-opened because she was convinced her husband had committed suicide. She claimed to have studied the KIG’s doubts about the official reason for her husband’s death, but gave few reasons for her thinking it was suicide other than her husband’s anguish at the time. This was a blow which appeared to shut the door on further progress. However we persevered.

PARAMEDICS UNHAPPY WITH OFFICIAL CAUSE OF DEATH

I contacted the two paramedics who had attended the scene of Dr Kelly’s death and put them in touch with Antony Barnett of the Observer. They arranged to meet Barnett in the presence of their solicitor and gave him the material for his 12 December 2004 article, ‘Kelly Death Paramedics Query Verdict’ where their shock at the general absence of blood at the scene and scepticism over the official cause of death was described in detail. When the press arrived on their doorsteps, they gave a televised press conference.


MP NORMAN BAKER BEGINS HIS PRIVATE KELLY INVESTIGATION

In May 2005 one more letter - Due Process & the Kelly Inquest - was published in the New Statesman pointing up the subversion of due process. But media interest flagged, and it was not until MP Norman Baker came forward this year (2006) to announce that he had resigned his seat on the front bench to pursue a private investigation into Dr Kelly’s death that the case was injected with new life. According to a Guardian report:

Mr Baker said he wanted to return to the issue because the 2003 Hutton inquiry had "blatantly failed” to get to the bottom of matters. He vowed to question ministers and to unearth new facts in a bid to establish the "truth" of the case.

After a few months on the case he wrote a major article for the ‘Mail on Sunday’ vowing to prove Dr Kelly’s death was not suicide. His new finding was that the Coroner had irregular and clandestine meetings with Department of Constitutional Affairs officials and representatives of the forensic staff just prior to the issuing of a full death certificate - before Lord Hutton had even started to examine the details of Dr Kelly’s death. Normally a temporary death certificate is issued pending a full inquiry. In this case it seems, the rules were bent.

In 2006 the KIG launched a NEW DR DAVID KELLY BLOG and is now working in conjunction with Mr Baker. Significant progress is being made. Watch this space…..

* Dr Kelly was found dead on 18th July 2003; Lord Hutton was appointed only a few days later - on 22nd July.














5 comments:

tina louise said...

Excellent news that this is still being investigated and argued. Well done to those persistent enough to have stayed with it and intelligently and honestly put forward the facts and doubts.

I am active against the war in Iraq and find that as I delve deeper into the reasons our government states for being there - that the more murky and ugly the trail gets with lies and manipulations. It is tragic, terrifying and essential that all make a stand.

The toughest part? Knowing which event/lie/threat to stand against - how much can each of us do? Thank goodness for people like you and for all who make a stand.

Namaste, Tina
www.armsagainstwar.info

St_Aubyn said...

It was Mr Blair who called for an urgent inquiry into the death of Dr David Kelly. It was the process of this inquiry which ultimately supplanted the coroners inquest. Dr Kelly is the only British citizen who has been a single victim of an incident resulting their sudden death and yet not had a coroners inquest return a verdict.

The Hutton inquiry was not the appropriate means by which to conclude the cause of Dr Kelly's death. Lord Hutton's remit was to 'urgently' examine the 'circumstances surrounding' the death of Dr Kelly. An inquiry of this type usually relates to an incident - such as a rail disaster - where individual's cause of death is not so much at question but rather to question the cause of the incident itself. The terms of reference given to Lord Hutton are no wider in their scope.

The coroner, Nicholas Gardiner, should have been allowed to concluded his inquest before the Hutton inquiry commenced. Failing this the coroner should not have subsequently waited for Lord Hutton's findings. His delay in reconvening the coroners inquest anticipated Lord Hutton may drawn a conclusion in his report as to the probable cause of death. Lord Hutton should not have attempted to draw a conclusion as to the cause of death as this was outside of his remit and the "rigours that are normally undertaken at a coroner's inquest simply were not fulfilled" (I quote coroner Dr Michael Powers).

Nothing obvious was to be gained by so very 'urgently' commencing Lord Hutton's inquiry. Indeed it was inappropriate to have urgently commenced the inquiry without the coroner having first confirmed how Dr Kelly died. From the outset this was a prejudicial conclusion of the Hutton inquiry. An inquest's verdict of suicide and murder has to be established beyond reasonable doubt. If the coroner had returned an open verdict the thrust of the Hutton inquiry would have been wholly different or perhaps not occurred at all.

Anonymous said...

Song by Thom Yorke (of Radiohead) re David Kelly

(Video here)

Harrowdown Hill

Don't walk the plank like I did
You will be dispensed with
When you've become inconvenient
In the harrowdown hill
Where you went to school
That's where I am
That's where I'm lying down

Did I fall or was I pushed?
Did I fall or was I pushed?
And where's the blood?
And where's the blood?

I'm coming home
I'm coming home
To make it all right
So dry your eyes

We think the same things at the same time
We just cant do anything about it

So don't ask me
Ask the ministry
Don't ask me
Ask the ministry

We think the same things at the same time
There are so many of us
So you can't count

We think the same things at the same time
There are too many of us
So you can't count

Can you see me when I'm running?
Can you see me when I'm running?
Away from them

I can't take their pressure
No one cares if you live or die
They just want me gone
They want me gone

I'm coming home
I'm coming home
To make it all right
So dry your eyes

We think the same things at the same time
We just cant do anything about it

We think the same things at the same time
There are too many of us
So you can't count

It was a slippery slippery slippery slope
It was a slippery slippery slippery slope
I feel me slipping in and out of consciousness
I feel me slipping in and out of consciousnes

St_Aubyn said...

The 1999 amendment to the Coroners Act 1988 provides a section 17A allowing the following:

If the Lord Chancellor tells a coroner that there is going to be a public enquiry (into the events surrounding the death) before the coroner's inquest is likely to be completed, the coroner shall adjourn their inquest. (So long as the Lord Chancellor considers that it is LIKELY the cause of death will also be investigated by the inquiry and that there is an absence of any exceptional reason to the contrary).

In the event of an inquest so being adjourned, the coroner should produce a death certificate stating the necessary particulars concerning the death so far as they had been ascertained at that point in the inquest.

If the coroner does not eventually resume the inquest, they must ultimately issue a death certificate stating the findings of the public inquiry.

St_Aubyn said...

The 1999 amendment to the Coroners Act 1988 section 17A 1(b) allows for the coroner to adjourn the inquest, if there is to be a public enquiry, only 'in the absence of any exceptional reason to the contrary'.

The coroner should resume the inquest 28 days after the publication of the public inquiry's findings (or if directed by the Lord Chancellor 28 days after the public inquiry is concluded) if in the coroner's opinion there is exceptional reason for doing so - Coroners Act 1988 section 17A-4.

The exceptional reason for the coroner to have not adjourn the inquest should have been that cause of death had not been established and that the public inquiry was not the correct mechanism to conclude a finding. The exceptional reason for the coroner to have resumed the inquest following the public inquiry was that the 'rigours that are normally undertaken at a coroner's inquest simply were not fulfilled'.