Trial By Error: Coroner in Boothby O’Neill Inquest Issues Report to Prevent Future Deaths

By David Tuller, DrPH

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For two weeks in late July and early August, His Majesty’s Assistant Coroner Deborah Archer heard testimony regarding the death of Maeve Boothby O’Neill, a 27-year-old woman who died of malnutrition after three hospitalizations at the Royal Deven and Exeter Hospital (RDE) failed to address her severe case of ME. While Archer’s report on the circumstances of Maeve’s death found no liability on the part of medical personnel and social service workers, it did highlight areas of concern.

On September 27th, Archer held another hearing to obtain testimony from Dr Anthony Hemsley, the RD&E’s medical director, about strategies to prevent such deaths in the future. The event was covered in the UK media, with The Times taking significant interest in the developments; this is not surprising, since Boothby O’Neill’s father, Sean O’Neill, is a Times correspondent. (For American readers, this is NOT The New York Times but Rupert Murdoch’s London news organization.) Now Archer has issued a Report to Prevent Future Deaths under Regulation 28 of the relevant legal guidelines.

I will likely post more on these events and the coverage of them soon, but for now here is the coroner’s Regulation 28 report in full.

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