R v Malcherek [1981] 2 All ER 422; 1981] Crim LR 401; [1981] 1 W.L.R. 690

In homicide cases where a victim is connected to a life-support machine and later declared brain dead by doctors, the chain of causation is crucial.

• If there’s no evidence that the original assault wound wasn’t a continuing cause of death, the issue of causation remains for the jury.

• Disconnection of life support based on brain death doesn’t necessarily break the causation link.

Issues about the adequacy of testing can arise in cases involving medical evidence of brain death.

• Suppose tests for brain death are claimed to be insufficient or improperly conducted.

• In that case, the appeal court may consider whether such evidence was properly admitted and if its reception affects the trial’s fairness or outcome under the Criminal Appeal Act 1968, sections 23(1) and 23(2).

Carol Wilkinson and others (“Victims”) of assaults requiring medical treatment were given standard care, including connection to life-support systems.

• In each case, doctors later determined that the victim was "brain dead," rendering the life-support treatment unnecessary.

• The life-support system was then disconnected, resulting in the cessation of all bodily functions.

• Each assailant was charged with murder.

• At the time of the cessation of bodily functions, there was no evidence suggesting that the original wound or injury was not a continuing, operating, and substantial cause of death. 

The judge decided to withdraw the issue of causation from the jury, leading to the assailant’s conviction.

On appeal, the court considered whether the causation issue should have been presented to the jury and whether further medical evidence regarding the adequacy of brain death tests should be admitted.

The appeal was dismissed, and the applications were refused for the following reasons:

1. The fact that the victim had died despite or because of the medical treatment provided by skilled practitioners did not absolve the assailant of responsibility for the death.

   • The discontinuance of medical treatment in these circumstances did not break the chain of causation between the initial injury and the victim's death.

   • Consequently, the issue of causation had been properly withdrawn from the jury.

2. The additional medical witnesses sought to be called could not provide evidence that would alter the fact that the assailant’s actions remained the operating cause of death in each case.

   • Therefore, their evidence could not provide grounds for allowing the appeal. It was neither necessary, desirable, nor expedient to receive the proposed additional evidence.

This case offers a significant exploration of the principles of causation in homicide cases, particularly in the context of modern medical practices.

• Central to this case was the issue of whether the act of disconnecting life support systems by medical professionals could be deemed to break the chain of causation established by the original assault.

The Court of Appeal upheld the trial judge’s decision to withdraw the causation issue from the jury, emphasizing that despite sophisticated medical interventions, the initial assault remained a continuing and substantial cause of death.

• This decision underscores the principle that, in determining legal causation, the focus remains on whether the original injury was still an operative cause of death at the time when life-support measures were terminated.

• By dismissing the appeal and refusing the applications to introduce further medical evidence regarding the adequacy of brain death tests, the court reinforced the notion that legal causation focuses on whether the original injury was a substantial factor in the death, irrespective of subsequent medical treatment.

• The judgment reflects a pragmatic approach, acknowledging the complexities of modern medicine while affirming that medical decisions, when made in good faith and according to accepted practices, do not necessarily sever the causal link between an initial injury and death.

The case highlights the judicial commitment to maintaining a clear boundary between medical practice and legal causation, ensuring that responsibility for death remains appropriately attributed to the initial wrongful act, regardless of subsequent medical interventions.