Poppi Worthington ~ Inquest

On 12th December 2012, Poppi Worthington died in hospital at the age of 13 months.  In late 2017, HM Coroner for Cumbria (Mr David Roberts) conducted a further inquest and announced his determination on Monday 15th January 2018.   A report on the inquest is at BBC NEWS 15th January.  The BBC has also published a useful timeline of the case.

The inquest: Review of evidence, findings and conclusion

The Coroner's conclusions (at pages 86 and 87) are



"On the 12th December 2012 the Deceased was at her home address when, at some time after 2.30 am, she was taken from her cot to a double bed where she was anally penetrated. She subsequently went to sleep in the double bed with an adult sleeping close to her.  She was suffering from an upper respiratory tract infection and her ability to breathe was compromised by her unsafe sleeping environment. Shortly before 05.56 hours she was found to have stopped breathing. Resuscitation was commenced at her home and was continued by the emergency services and at the Furness General Hospital to where she was taken, but she was asystolic throughout. Despite resuscitation her death was pronounced at 07.07 hours at the Furness General Hospital, Barrow in Furness, Cumbria.

The Deceased died as a result of her ability to breathe being compromised by an unsafe sleeping environment."

The Police investigation into Poppi's death proved to be unsatisfactory and led to this statement by the Chief Constable of Cumbria.  The statement apologises to Poppi's family for the deficiencies in the initial police investigation. "It is clear that the initial investigation surrounding Poppi’s death launched in 2012 has done little to assist the Coroner in coming to a conclusion on how Poppi died. I greatly regret this."

High Court proceedings came before Mr Justice Peter Jackson.  The learned judge's first judgment is dated 28th March 2014.  The second judgment (dated January 2016) is reported as  F v Cumbria County Council [2016] EWHC 14 (Fam) where Peter Jackson J noted (para 122) - "For the court to conduct a further hearing in a case of this kind is highly unusual. It does not do so simply because others hold different views to those of a witness whose evidence has been accepted. This further hearing took place because it was asserted that there was evidence capable of establishing an alternative plausible hypothesis for the bleeding, namely that it may have come from congested blood vessels that had been affected by a viral infection. But even before the hearing began, that assertion had vanished like frost in May."

The learned judge continued (paras 123 and 124):

"In conclusion, stepping back and reviewing the evidence as a whole, I arrive at the same view as I expressed at paragraph 142 of the previous judgment:

Shorn to its essentials, the situation is one in which a healthy child with no medical condition or illness was put to bed by her mother one evening and brought downstairs eight hours later by her father in a lifeless state and with troubling injuries, most obviously significant bleeding from the anus. Careful assessment of the meticulous pathological and paediatric evidence has clearly established that the injuries were the result of trauma from outside the body.

My finding at paragraph 152 was that the father perpetrated a penetrative anal assault on Poppi either using his penis or some other unidentified object. That remains my conclusion. Some witnesses at this hearing have expressed the view that penetration with a penis would have been expected to cause more obvious injuries. That may be so, but the evidence does not exclude any one of a number of distressing possibilities. As I said before, it is not possible to reconstruct the exact sequence of events that led to Poppi's collapse without a truthful account from the father."


It is reported that, during the 2017 Inquest, Poppi's father refused to answer a considerable number of questions and cited Rule 22 of the Coroners Rules 2013 as his reason.  Rule 22 states: "No witness at an inquest is obliged to answer any question tending to incriminate him or her."

It is both unwise and impermissible to draw any conclusions regarding any possible criminal liability from this.  The CPS bring charges if there is a realistic prospect of conviction and, at a criminal trial, the criminal standard of proof applies - "beyond a reasonable doubt."  This is in contrast to the civil "balance of probabilities" standard of proof.  The Chief Constable indicated that he would be discussing the matter with the Crown Prosecution Service "in order to determine possible courses of action."

The Coroner noted the difference between an Inquest and proceedings in the courts - "The nature, purpose and role of an inquest is different to that of the High Court proceedings. The Family Court proceedings were concerned with what could be established on an application by the Local Authority, after applying a burden and a single standard of proof, whereas an inquest is an inquiry in which there is no relevant burden of proof and two different standards of proof are  potentially relevant. There are no parties to an inquest but simply Interested Persons. No-one is presenting a case or has to prove anything. The inquest is an inquiry to establish the medical cause of Poppi’s death and how it came about, and to reach a conclusion as to the death; it was not necessary for the Judge in the Family Court proceedings to ascertain those matters and he did not do so."

HM Coroner for Cumbria retires this year after 33 years distinguished service and will be replaced by Kally Cheema - Whitehaven News.

CommunityCare 15th June 2016 - Serious case review