Inquest Case Law Summaries

Where a party is dissatisfied with the outcome of an inquest, there are procedures to challenge the outcome by way of judicial review or a Rule 13 reopening application.

Read our digested inquest cases below:-

Legal Aid and Costs:

Legal Services Commission v Humberstone (Lord Chancellor intervening) [2010] EWCA civ 1479  Read the full report.The deceased died after receiving medical treatment for an asthma attack from the ambulance service. His mother brought successful judicial review proceedings against the refusal of the LSC to grant funding for full legal representation for the family at the inquest. The LSC lost on appeal. The Court of Appeal held: The enhanced procedural duty of Art 2 ECHR arose because of the much narrower range of circumstances where there was an arguable case of breach by the state (here the ambulance service) of the Art 2 substantive duty to protect the life of those in its direct care. In the context of allegations against hospital authorities the narrow duty only arose where the allegations were of systemic failure by the state and did not arise where the allegations were only of individual negligence. Save for extremely unusual, funding for representation would be provided only in the circumstances where the law required it to be provided- where Article 2 obliged the state to conduct an effective investigation into the circumstances of a death and the representation was likely to be necessary to enable the deceased’s close family to play an effective part in that investigation. The Court of Appeal made adverse comments on other aspects of the Lord Chancellor’s funding guidance. See also the first instance decision on the High Court

Fullick V The Commissioner of Police of the Metropolis [2019] EWHC 1941 (QB) Read the full report

This was an appeal against the Deputy Master’s order when assessing the costs of a civil claim that was settled before a letter of claim and prior service of proceedings. The Deputy Master awarded the claimants’ costs incurred at two Pre inquest Review hearings and a six-day inquest into the death of Ms Susan Sian Jones. She died at a police station where she had attended voluntarily. The jury gave a narrative conclusion that the death had resulted from methadone and alcohol intoxication coupled with inadequate police policies, procedures and training.  Slade J in her judgment emphasised that each application for costs in a civil claim and related to an inquest must be judged on its own facts as the whether the amount claimed as costs is for an allowable item, and whether it is proportionate and reasonable. The court would only interfere if the Deputy Master had erred in law or made a perverse decision. The Deputy Master did not err in taking into account that the issues raised in the civil claim were not only financial but were of importance to the deceased’s family. The Inquest proceedings held the police to account in some measure for the death. The settlement of the claim gave rise to an agreement to revise policies, protocols and training which should avoid for the future the situation which arose here. The issues were of wider public interest than that of the claimants. The steps taken in the Inquest were relevant to the civil claim. On the issue of proportionality, the costs incurred by a Claimant in the Inquest must be relevant to the issues of the civil claim to be recoverable as costs in that claim.  Two items of the Bill of Costs were remitted for assessment so that the relevance to the civil claim and the proportionality of the amount claimed could be properly identified.

Practice and Procedure:

R (Hair) v HM Coroner for Staffordshire (South) [2010] EWHC 2580 Admin  Read  the full report As part of an application for judicial review seeking to quash an inquest verdict it was argued that Rule 40 of the Coroner’s Rules 1984, which prevents any person addressing the Coroner or Jury on the facts, prevented the jury reaching a proper conclusion on central issues of fact and was incompatible with Article 2 ECHR. This was rejected by the judge “Rule 40 has been around for a long time, and, whilst it has attracted comment, no-one has suggested that it is invalid and Middleton supports the proposition that the Coroner’s Rules are, in general terms, ECHR-compatible.” The ability to make submissions as to the facts, whether to the coroner or the jury, is not necessary to ensure compliance with Article 2.

R (Lewis) v HM Coroner for Shropshire  [2009] EWCA Civ 1403 Read the full report. The Court of Appeal held that a coroner is not required to leave to a jury questions or findings unless there is evidence on which the jury could conclude that they were probably causally relevant to the death in question.

R (P) v HM Coroner for Avon [2009] EWCA Civ 1367  Read the full report. In this Court of Appeal case it was determined that a short form and narrative verdict can be combined. On the facts of the case, short form verdicts were insufficient so the jury had to be given the opportunity to return a narrative verdict

R (de Menezes) v HM Assistant Deputy Coroner for Inner South London [2008] EWHC 3356 Admin Read the full report  This was the case involving the police shooting of Mr de Menezes at Stockwell tube station.  The family of the deceased sought to challenge the fact coroner refused to put certain questions to the jury. For example “Have you identified any other factor which you consider made more than the minimal causal contribution to the death of Mr D? If so, what are they?” This challenge was rejected. It was held that the existing questions were sufficient to enable the jury to answer the who, how, when and where questions. It was a matter for the coroner’s discretion how best in the particular case to elicit the jury’s conclusion on the central issue or issues. There was nothing in the coroner’s approach that was Wednesbury unreasonable. Had the questions been asked there was a risk of infringing the statutory rules 36(2) and 42 by appearing to determine civil or criminal liability. The questions created a risk of the jury making contradictory findings.

 Touche, R (on the application of) v HM Coroner For Inner London North [2001] EWCA Civ 383 Read full report Mrs Touche gave birth to twins then subsequently died of a brain haemorrhage due to increased blood pressure which the hospital had failed to adequately monitor. The coroner had formed the conclusion that the death had occurred from natural causes and refused to hold an inquest. This judicial review claim went to the Court of Appeal. Held: It was for the coroner to decide whether or not a death was unnatural. That is not challengeable unless it was Wednesbury unreasonable or involved a self-misdirection on the law.   An inquest should be held whenever a death is wholly unexpected and there are reasonable grounds for suspecting that it resulted from culpable human failure that could turn a natural death into an unnatural one.

Brown v HM Coroner for Norfolk [2014] EWHC 187 (Admin) read judgment

The Chief Coroner sat as a judge in this case with Pitchford LJ. The bereaved family were dissatisfied with inquest process and in particular how the pre-inquest review had been conducted. The application to have the findings of the original inquest quashed and an order for a new inquest was granted. In paragraphs 38-45 of the judgment very useful guidance was given by the Chief Coroner about the approach to be taken at pre-inquest review hearings.  There were other observations on other areas of good practice that a coroner should adopt such as not giving the impression of bias or favouritism in dealing with interested persons or appearing to be too familiar or close to an interested person such as the police in letters or emails.

R (on the application of The Commissioners for HMRC) v HM Coroner for the City of Liverpool and others EWHC [2014] 1586 (Admin) Read the full report  HMRC had a claim for judicial review dismissed. It had applied seeking quashing orders against Notices issued by the coroner pursuant to Schd 5 Coroners and Justice Act 2009. The Notices required HMRC to provide an occupational health history relating to the deceased because the coroner wished to investigate whether his death was as a result of Industrial Disease.  It was held that Schd 5 binds the Crown by necessary implication. Therefore HMRC was bound to comply with the Notices.

R (Fullick) v HM Senior Coroner for Inner London North [2015] EWHC 3522 (Admin) A vulnerable witness at a police station had stopped breathing whilst left unattended in an interview room. She died later after an emergency admission to hospital. The High Court considered whether the coroner was required hold the inquest with a jury under Section 7(2)(b) of the 2009 Act – that there was sufficient evidence or information before the coroner to have reason to believe that the death resulted from the act or omission of a police officer … in the purported execution of the officer’s duty.  The court adopted the approach of Hickinbottom J in R (Davey) v HM Coroner for Leicester City and South Leicestershire [2014] EWHC 3982 (Admin) [7] “Reason to suspect” is a low threshold for the triggering of the obligation to empanel a jury. “Suspicion” for these purposes being a state of conjecture or surmise arising at the start of an investigation in which obtaining prima facie proof is the end.  The court gave observations at paragraphs 41-46 on when it would be appropriate for a coroner to exercise the discretion under section 7(3) to summon a jury.  The court urged that in all cases where the issue of Article 2 is raised for consideration the coroner should respond with clarity.  Interested persons needs to know whether the coroner considers Article 2 arguably engaged, either as a general duty or operational duty so that they can know whether the state’s procedural duty of investigation is triggered.

R(LF) v HM Senior Coroner for Inner South London [2015] EWHC 2990 (Admin) Read the full report A person who died whilst in intensive care in hospital was not in state detention within the meaning of S7(2) (a) CJA 2009. Therefore, it was unnecessary for the coroner to empanel a jury.

Shafi v HM Coroner for East London [2015] EWHC 2106 (Admin) Read the full report  Death in custody abroad.  S7(2)(a) CJA 2009 does not make it mandatory for the coroner to sit with a jury in every case of this type. The case also considered the attendance of witnesses and the application of Rule 23 of the Coroner’s (inquest) Rules 2013 for admitting written evidence instead.

Inquest into the death of Private Sean Benton 28 June 2017 Ruling by the nominated coroner HH Peter Rook QC upon whether a jury should be summoned under S7(3) CJA 2009. The coroner heard full submissions on behalf of the family and other interested persons as to whether he should exercise his discretion to sit with a jury. He concluded that the presumption under S7(1)(a) CJA 2009 in favour of him sitting alone without a jury had not been displaced.

R:AB (Application for reporting restrictions: Inquest) [2019] EWHC 1668 (QB) Read the full report.

The High Court dismissed an application by Worcester County Council for an order for reporting restrictions under S39 Children and Young Persons Act 1933 with respect to the forthcoming inquest of a 17-year-old who had died in custody. It was held there had been breaches of S12(2) Human Rights Act 1988 due to insufficient service of several potential respondents and non- parties who should have been served. These breaches went to jurisdiction and warranted dismissal of the claim. The court did not have jurisdiction to deal with the application. It should have been made to the coroner who had jurisdiction to make an order under S39 Children and Young Persons Act 1933.

R (Chidlow) V HM Senior Coroner for Blackpool & Fylde and others [2019] EWHC 581 (Admin) Read the full report.

The coroner refused to leave to a jury the issue of causation of the delay in the arrival of an ambulance and the death. The medical cause of death could not be established. The court heard evidence from a consultant in critical care and emergency medicine on the question of the deceased’s likely survival if he had arrived at A and E sooner. This included statistical evidence. The doctor gave careful consideration to the possible causes of death and had analysed the prospects of successful treatment in each case.   Paragraph 52 of the judgment identifies the principles to be applied when causation can be left to a jury. This includes how to approach statistical evidence. It was held that the coroner had erred in law by concluding the lack of a clear cause of death prevented the jury from being able to consider the possible causal effect of the delay in treatment. Establishing the medical cause of death would have assisted but was not essential to being able to form an opinion as to the effect of delayed treatment.

Smith R (on the application of) v HM Assistant Coroner for North West Wales [2020]EWHC 731 (Admin) Read the full report. The application for judicial review of the Assistant Coroner’s decision on 5 stated grounds was refused.  27-year-old Leah Smith hanged herself on 28 April 2017 and died in hospital on 2 May 2017. The Assistant Coroner treated the case as an Article 2 inquest. The inquest was concerned with the care Leah had received from mental health services during a short history of mental health issues as a result of suffering from an episode of psychosis. The coroner gave detailed reasons and provided a short narrative conclusion in the Record of Inquest. The judgment contains a reminder of the principles applicable to the threshold and standard of proof for causation as set out in  R (Tainton) v HM Coroner for Preston and West Lancashire [2016] and R (Chidlow) v HM senior coroner for Blackpool and Fylde [2019]. The Divisional Court refused to approve the proposed alternative wording for Part 4 of the Record of Inquest on the basis it would have compromised the essential brevity and simplicity of a Conclusion answering the question “ how, when and where and (this being an Article 2 case) in what circumstances the deceased came by his or her death.” The judgment also reminded of the prohibition from expressing any opinion on any matter unless relating to those questions. It had been appropriate for the Assistant Coroner to include the points that had been proposed in the amended wording in her reasons not the Conclusion.

Jones v HM Coroner for North Wales (East & Central) & Others  [2019] EWHC 1494 (Admin) Read the full report.   This was a claim for judicial review because the coroner had refused to admit and call evidence about allegations of sexual misconduct against the deceased. The case focused upon a coroner’s remit under S5 Coroner’s and Justice Act 2009 and his discretion to admit evidence when conducting a Jamieson inquest. This sort of inquest is directed at answering some simple and clear questions and is a fact finding exercise. Held: The coroner had directed himself properly in accordance with Jamieson and Law Sheet No5.

R v Duncan Lawrence Wimbledon Magistrates Court 30 October 2019 [Failing to comply with a summons]Mr Lawrence was the clinical lead and consultant at a specialist care home for people with mental health difficulties. The Assistant coroner conducting the inquest into the death of Sophie Bennett in February 2019 issued a summons for Mr Lawrence to attend the inquest and to disclose certain documents. He failed to comply with the summons.  Using his powers under Schedule 6 of the Coroners and Justice Act 2009 the Assistant Coroner fined Mr Lawrence £650 and referred the matter on to the police. The CPS brought a prosecution for withholding evidence/ documentation in a coroner’s inquest (also under the provisions in Schedule 6.)  Mr Lawrence initially pleaded guilty at the first Magistrates court hearing. He was unsuccessful when he tried to withdraw his plea. The District Judge sentenced him to 4 months imprisonment for frustrating the inquest process.  This is the first case where a criminal prosecution has been brought.

R (on the application of Dyer) v HM Assistant Coroner for West Yorkshire (Western) and others [2019] EWHC 2897 (Admin) Read the full report The Assistant coroner had granted applications for 16 police officers to give evidence at the inquest from behind screens. The direction had been given exercising the powers under Rule 18 of the Coroner’s (Inquests) Rules 2013. The inquest concerned the death of Andrew Hall a black man who died shortly after being in police custody. Directions granting anonymity were not challenged, but the family sought a judicial review of the direction for screens. Jefford J reviewed the legal framework and the wording of Rule 18.  This was summarised in paragraph 51 of the judgment: (i) There was nothing unlawful per se in the use of screens but there is a balancing exercise to be undertaken; (ii) Amongst the factors in that balancing exercise is the fundamental importance of open justice, that is why the provision of screens should only be ordered where necessary and to the extent necessary. The fact that the witness may still be available for cross-examination is relevant but not conclusive, as is the fact the family may have the opportunity to cross-examine; (iii) the impact on the witness is a further factor, that in itself is multi-faceted. The consideration of the impact on the quality of their evidence (and thus the interests of justice) may bring into play their subjective fears and concerns. But it is also necessary to consider whether those fears and concerns are objectively justified, and they may carry greater weight in the balance if they are. It was held the coroner had misdirected himself in law because he did not conduct the balancing exercise properly.  The coroner’s decision to permit screens was quashed  in 14 cases to the extent that the screens prevented the identified family members from seeing the police officers give evidence For the remaining 2 identified officers the decision to allow them to give evidence from behind a screen so that they were not visible to family members was upheld.

Article 2 EHCR cases:

Boyce, R (On the Application Of) v HM Senior Coroner for Teesside and Hartlepool [2022] EWHC 107 (Admin) – Read full Report – The case relates to a child who was in childrens services care but who was not securely detained. There was no justification for holding a full Article 2 inquest, but there is scope for greater scrutiny than in a standard inquest and that is what the coroner had agreed to do in any event. In summary, some inquests require elevated scrutiny of the circumstances that led to death and the states’s responsibilities and any failures in that regard. The case law is examined and the general observation that there is now little difference between a Jamieson inquest and a Middleton inquest. The inquisitorial scope is a matter for the coroner, and coroners are alert to the need to explore matters of concern. The judge did not interfere with the coroner’s case management decisions. This is an important case to read to understand where the dividing line may fall in cases where the state has some responsibility for the care of people. (January 2022)

Rabone and Anor (Appellants) v Pennine Care Foundation Trust (Respondent) [2012] UKSC 2  Read the full report The case involved a voluntary in-patient under the Mental Health  Act who committed suicide whilst on home leave. It was found that she was at “real and immediate risk of death”.  Article 2 positive operational obligation of ECHR applied to protect mentally ill patients who were not detained under the Mental Health Act 1983 where there was a real and immediate risk of suicide.

R (Antoniou) v (1) Central and North West London NHS Foundation Trust; (2) Secretary of State for Health; (3) NHS England [2013] EWHC 3055 (Admin). Read the case reportArticle 2 imposes procedural obligations on the State to investigate the circumstances of the death where a patient detained under Section 3 of the Mental Health Act 1983 takes their own life. It was held that these obligations are fulfilled by a coroner’s inquest. Unlike in prison and police station deaths, there need not be any independent investigation system prior to the inquest stage. As a matter of law the State did not have to institute the same system to investigate suicides of detained MHA patients.

R (Tainton v HM Senior Coroner for Preston and West Lancashire [2016] EWHC 1396 (Admin) Read the full report In an Article 2 inquest the coroner should have directed the jury to include in the Record of Inquest a brief narrative of the admitted shortcomings of the healthcare staff. Because causation had not been left to the jury the statement needed to be supplemented by an explanation that it could not be concluded that the shortcomings significantly shortened the deceased’s life.

Tyrell v HM Senior Coroner for County Durham and Darlington [2016] EWHC 1899 (Admin) Read the full report  Article 2 is not engaged when a death in custody was from the outset one of clearly natural causes. The cause of death had been established and then confirmed by post mortem. There was no indication of state involvement in the death of the sort that would trigger the procedural obligation under Art 2.

R (on the application of Parkinson) v HM Senior Coroner for Kent [2018] EWHC 150 (Admin) Read the full report The claimant sought (amongst other things) a judicial review of the coroner’s finding that the enhanced investigative duty under Article 2 did not arise in relation to the diagnosis and treatment of the deceased while she was at hospital. The judgment includes a review of the main authorities on the procedural obligations in Article 2.  Paragraphs 82-92 gives a summary of the relevant principles in Article 2 applicable to medical cases. Paragraph 89 reads “At the risk of over-simplification, the crucial distinction is between a case where there is reason to believe that there may have been a breach which is a “systemic failure” in contrast to an “ordinary” case of medical negligence.”

R (on the application of Maguire) V Her Majesty’s Senior Coroner for Blackpool and Flyde (defendant) and ORS [2019] EWHC 1232 (Admin) Read the full report The deceased lived in a care home. She suffered from Down’s Syndrome and MDL and needed 1:1 support for severely compromised cognitive and communication abilities. After admission to hospital she died of a perforated ulcer. There were questions about the care she had received. The inquest proceeded as an Article 2 inquest. The judgment in R (Parkinson) v Kent Senior Coroner [2018] EWHC 1501 (Admin) was handed down a few days before the inquest. In the light of that decision, the coroner ruled that the allegations against the carers and healthcare providers amounted to allegations of individual negligence and were outside the state’s obligations under Article 2. It was held that Parkinson is now authority for the proposition that a medical case (in which medical treatment may incur liability in tort) will not generally engage Article 2. In relation to the second ground for judicial review, the coroner had not made an error in law in withholding the conclusion of gross neglect from the jury.

Challenging an Inquest:

Duffy, R (on the application of) v HM Deputy Coroner for the County of Worcestershire & Anor [2013] EWHC 1654 (Admin) (19 June 2013) Read the full report. This case challenged the adequacy of the inquiry and the safety of the inquest verdict in relation to the death of a 14 month old baby. The deputy coroner had instructed an independent expert. She refused an application to adjourn the inquest and instruct a fresh expert when it became apparent during the evidence that the expert had no recent clinical experience in relation to some of the key issues. The deputy coroner had listed the case for 6 days but decided after hearing from the pathologist and the expert that she could reach a verdict with hearing any further evidence. The High Court Judge pointed out the complexities of some of the factual issues in the case. He concluded that in refusing to adjourn the deputy coroner had made certain specific material errors, and she also reached a conclusion which, on the balance of relevant factors, was not reasonably open and was at real risk of causing substantial injustice.  There was a material irregularity and the verdict needed to be quashed.

R (Warren) v HM Coroner for Northamptonshire [2008] EWHC 966 (Admin)  Read the full report. This was a fact specific case but is a good example of where there has been an attempt to challenge a coroner’s refusal to call a particular expert witness. The coroner was due to start an Article 2 inquest into a prison death. At a PIH he had refused to agree to call as an expert the consultant psychiatrist the family were inviting him to.  The judge concluded that the coroner’s reasoning why he was not going to call that specific expert was not Wednesbury unreasonable. However, if the coroner failed to call independent psychiatric evidence and independent evidence from a GP there would be a gap in the evidence which would make the inquest non-complaint with Article 2.

R (Sutovic) v HM Coroner Northern District of Greater London [2006] EWHC 1095 (Admin)  Read the full report The coroner had returned an open verdict. The claimant had gathered fresh evidence and had brought judicial review proceedings and a case under S13 Coroners Act 1988. The claimant was seeking to rely on procedural irregularity, insufficiency of investigation and fresh evidence. This case reviewed the wording of S13 previous authorities on the circumstances when it is appropriate to quash an inquisition and order a fresh inquest. Paragraphs 53-55.  The factors of central importance are an assessment of the possibility (as opposed to the probability) of a different verdict, the number of shortcomings in the original inquest, and the need to investigate matters raised by new evidence which had not been investigated at the inquest: In cases in which the court is satisfied that a different verdict is not possible or doubts that it would be, the fact that the deceased died in custody may be “a compelling additional factor” (R v West Sussex Coroner, ex p Homberg (1994) 158 JP 357, per Simon Brown LJ Transcript 26 January 1994, page 37) in concluding that a further inquest is necessary or desirable in the interests of justice.

Dowler v HM Coroner for North London [2009] EWHC 3300 (Admin)  Read the full report. This was an application by the doctor who had treated the deceased prior to his death to quash the inquisition and seek an inquest before a new coroner. The application for an Attorney General’s Fiat was made by the doctor because there had been a finding of neglect and she had not been called to give evidence at the inquest, had not received notification that it was taking place, and had not been represented.  The neglect finding could have seriously damaged her professional reputation. Although the coroner had conceded there should be a new inquest the divisional court carried out its own review and concluded there had not been a sufficiency of investigation at the original inquest and there was new evidence which should be considered. It was appropriate in the interests of justice to hold the inquest in front of a different coroner in view of the strong adverse comments made against the doctor by the original coroner and to avoid any actual or perceived bias if he heard the fresh inquest.

Duggan v HM Coroner for Northern District of Greater London [2010] EWHC 1263 (Admin) Read the full report This was an application by the mother of the deceased to quash the inquisition and seek an inquest before a new coroner. She was unhappy with the verdict returned by the coroner that her son had sustained fatal injuries as a result of a road traffic collision in rural Germany. The police investigation in Germany had concluded he had committed suicide by running into the road. The family were unhappy that the post mortem had not established how the fatal injuries had been sustained or the exact cause of death. Shortly before his death the deceased had made a number of highly distressed telephone calls to his mother and girlfriend asking for help. The coroner concluded he had been in a state of terror.  The family commissioned several expert’s reports to try and rebut the theory that the deceased had been hit by cars. The court was satisfied that is was necessary and desirable in the interests of justice for there to be a fresh inquest. The fresh evidence could alter the verdict, raised issues of causation and whether there could have been foul play. It was appropriate to hold the new inquest in front of a different coroner.

Jones v HM Coroner for the Southern District of Greater London and Virdi [2010] EWHC 931 (Admin) Read the full report. The deceased had died from an overdose of fentanyl.  The coroner returned an open verdict. The claim to have the inquisition set aside on the grounds of insufficiency of inquiry and fresh evidence was upheld by the Administrative Court. Apart from the fact there had been insufficient enquiry into the means by which the deceased came to die from fentanyl toxicity there was a possibility that a different verdict of accidental death might be returned. Also there was a wider public interest in a full inquiry such as whether the medical profession was aware of the possible danger to life presented by the prescription of fentanyl. Although it would be a matter for the coroner, the fresh inquest should be before a jury.

R(Mack) v HM Coroner for Birmingham [2011] EWCA civ 712  Read the full report The case involved an attempt to quash an inquest because of the refusal of the coroner to call a certain witness the family had requested in relation to a hospital death. The coroner only called one consultant who had dealt with the deceased early on but had not been the treating clinician in the period leading up to his death. It was felt this left a gap in the inquiry because there were limitations to the evidence the consultant could give based solely on the medical records especially where there were concerns about a whole series of failings in the treatment given.

Cooper, R (on the application of) v HM Coroner for North East Kent [2014] EWHC 586 (Admin) Read case report This was an application for permission for judicial review made mid inquest to challenge the decision of the Senior Coroner to leave to the jury the conclusion on the issue of unlawful killing. (This was a U-turn from an earlier indication when the inquest had to be adjourned.)  Mitting J considered the question whether the Administrative Court should as a matter of settled practice or principle entertain such an application mid- inquest.  He set out 5 reasons why in his view challenges of this kind should not in the ordinary case be entertained by the High Court.

Lagos,R (on the application of) v HM Coroner for the City of London [2013] EWHC 423 (Admin). Read the case report.This was an unsuccessful claim for judicial review relating to the verdict and whether the procedure adopted at the inquest had been unfair.  Although the legal framework considered was under the 1988 Act and 1984 Coroner’s Rules it has been carried through into the 2009 Act and 2013 Rules. The Claimant maintained the coroner should have returned a verdict of suicide. The coroner returned an open verdict.  This case was used as a reminder that in law a coroner has to be sure that the deceased intended to commit suicide and did in fact do so. All other possible explanations for the death had to be excluded. The coroner’s conclusion can only be challenged on the basis that no reasonable coroner could have reached this conclusion on the evidence. The Claimant complained about witnesses who were not called, the evidence given and lack of a proper opportunity to question them.  Again this case was used as a reminder that the coroner’s selection of witnesses may only be challenged if unreasonable in a Wednesbury sense. There were some concerns about the way the coroner intervened when the Claimant was asking questions it was not found to be sufficiently serious to amount to procedural unfairness. The Claimant had not objected to certain witness statements being read.

Frost V HM Coroner for West Yorkshire (Eastern District) [2019] EWHC 581 (Admin) Read the full report

The case was an application under S13 Coroners Act 1988 for a fresh inquest after an Attorney General’s fiat. In 1966 the inquest took place into the death of Elsie Frost who had been murdered. Under the law in force at that time the inquest verdict could name the believed perpetrator. The inquest jury named Ian Bernard Spencer as the person responsible for Elsie’s murder. In the criminal proceedings no evidence was offered.  Mr Spencer has since died. A fresh police investigation started in 2015 implicated another man in Elsie’s murder but he died before a decision on whether to bring criminal charges was made. The judgment is a useful review of the case law on S13 cases. The passage of 53 years had not vitiated the public interest, and the fact that Mr Spencer and the subsequent suspect had died did not render the process of a fresh inquest futile, unnecessary or undesirable. It was necessary and desirable that a new inquest be ordered.

Bias and Waiver

R (Shaw) v (1) HM Coroner (2) Assistant Deputy Coroner for Leicester City and South Leicestershire and others. [2013] EWHC 386 (Admin). Read the full report.  The claimant who was the daughter of the deceased failed in her claim for judicial review based on multiple grounds. The deceased was 86. He had been diagnosed with a defective heart valve. Instead of having open heart surgery he underwent a new procedure (TAVI). Due to complications his chest had to be opened in order to stem a bleed. He died shortly after surgery.  The coroner appointed a QC as an assistant deputy coroner to hold the inquest. This was done with a jury over 13 days. Although the case dealt with other issues such as the legality of the appointment of an assistant deputy coroner, and whether the delay of 3 ¼ years between the death and the inquest was unlawful, it is of most interest on the questions of presumed and apparent bias, and waiver [paragraphs 31-62, 100-105]  In December 2010  at the start of a pre inquest review hearing the assistant deputy coroner disclosed that he was a friend of someone who had been the CEO of the hospital trust where the death had occurred. Enquiries made during that hearing established that the CEO had ceased to work for the trust before the deceased had his TAVI operation. The assistant deputy coroner refused an application made by the claimant’s counsel to recuse himself.  There were no further attempts on behalf of the claimant to renew that application or to apply for judicial review before the inquest started.  On a comprehensive review of the authorities it was held that the facts did not give rise to any question of presumed bias. Turning to the question of apparent bias the court adopted the test from Porte v Magill [2002] AC 357 at para 103 – whether a fair minded and informed observer having considered the facts would conclude that there was a real possibility the decision maker was biased. It held there was no apparent bias in this case.  Turning to the issue of waiver, it was held that the claimant had been is possession of all the facts necessary to challenge the assistant deputy coroner’s refusal to recuse himself. Her decision not to do so amounted to an unequivocal waiver. It was observed that a decision on refusal to recuse could and should have been challenged immediately by judicial review. It was incumbent on the claimant to make the challenge before the inquest started rather than waiting and saving the point for later.

Disclosure and Public Interest Immunity:

Worcestershire County Council and Worcestershire Safeguarding Children Board v HM Coroner for the County of Worcestershire [2013] EWHC 1711 (QB) Read the case report.The Coroner applied to the High Court for permission to issue witness summonses against the LSCB in order to secure disclosure of the underlying Individual Management Reviews and Information Reports to the Serious Case Report Overview. The LCSB applied to have the summonses set aside claiming public interest immunity. Baker J held: (1) The Coroner was entitled to have disclosure of the underlying reports as well as the Overview Report; (2) The Coroner was entitled to have full disclosure so that he could decide what witnesses to call and what issues should be considered at the inquest; (3) Where there was a claim against disclosure on public interest immunity grounds it was necessary to balance the perceived public benefit it affords against the public benefit of disclosure; (4) The question of any further disclosure is a matter for the Coroner having taken into account any further arguments in favour of non-disclosure and subject to the supervisory jurisdiction of the court, thus maintaining sufficient safeguards to those properly seeking non-disclosure.

Leaving verdicts to a jury:

R (Secretary of State for Justice) v HM Deputy Coroner of Eastern District of West Yorkshire [2012] EWHC 1634 (Admin) Read the judgment. This expanded the Galbraith test. In deciding whether or not to leave a particular verdict to a jury coroner’s should apply a dual test: 1) Is there evidence on which a jury properly directed could properly convict; and 2) If so, would it be safe for the jury to convict on the evidence before it?

Lawful Killing

R (Duggan) v HM Assistant Deputy Coroner of the Northern District of Greater London and others EWHC [2014] 3343 (Admin) Read the full report  This was a judgment of a 3 strong court including the President of the QBD, and the Chief Coroner. It concerned the inquest into the death of Michael Duggan who was shot by a police officer. The jury returned a verdict of lawful killing. The claim for judicial review sought to challenge that verdict on several grounds. Permission had previously been refused on 2 of the grounds. On re-consideration, the court also refused to consider those grounds.  On ground 1 it was held it was open to the jury to conclude lawful killing.  Ground 2 concerned the nature of the test for lawful killing. In considering this ground the court carried out a comprehensive analysis of the development of 4 aspects of the material law; the law of self-defence in England and Wales; the meaning of unlawful killing and lawful killing at the conclusion of an inquest; the content of the Article 2 procedural obligation; and Strasbourg jurisprudence and justifiable killing. It was held that the conclusion of lawful killing is one which would amount to the crime of murder, manslaughter or infanticide but for the presence of an additional factor which justifies it. It signifies the jury’s conclusion not only that they are not sure a homicide was committed but also a conclusion that it probably was not. It says nothing about civil liability. In relation to ground 3 it was held that based on the direction the coroner gave the jury could not have been confused whether or not Mr Duggan’s death resulted from a lawful killing.  The court went on to stress what conclusions of lawful killing do not mean. They do not relieve from liability in tort.  It was not the purpose of the inquest to determine civil liability. In civil proceedings the balance of probability and the ingredients are different and may provide a different answer to the very difficult question posed by the case.

Decision making and Expedited Decisions

R(1) Adath Yisroal Burial Society (2) Ita Cynerman v HM Senior Coroner for Inner North London (Defendant ) and Chief Coroner for England and Wales (Interested Party) [2018] EWHC 969 (Admin) Read the full report This was a claim for judicial review to challenge the lawfulness of a policy adopted by the senior coroner on 30/10/2017 to the effect that “No death will be prioritised in any way over any other because of the religion of the deceased or family either by the coroner’s officers or coroners.” This resulted in Muslim and Jewish families facing delays in the burials of family members. It was referred to as a “cab rank policy”. The High Court considered the issues of: Fettering of Discretion, Irrationality, breaches of Articles 9 and 14 of the ECHR, Indirect Discrimination under the Equality Act 2010 and Public Sector Equality Duty. Judicial Review was granted on all grounds except Public Sector Equality Duty. Paragraph 160 of the judgment pulls together and summarises all the legal threads of the judgment. On 17 May 2018, as a result of the judgment the Chief Coroner published new Guidance 28: Report of death to the Coroner: Decision Making and Expedited Decisions.

Standard of Proof for Suicide Conclusion

Maughan, R v Senior Coroner for Oxfordshire [2018] EWHC 1955 (Admin)  Read the full report. This was a claim for judicial review after the jury in a prison death case returned a narrative conclusion of suicide applying the civil standard of proof, balance of probabilities. Legatt LJ and Nicol J carried out a comprehensive review of the case law before ruling on the standard of proof to be applied in order to reach a conclusion of suicide. They decided that the true position is that the standard of proof required for a conclusion of suicide, whether recorded in short form or as a narrative statement is on the balance of probabilities bearing in mind that such a conclusion should only be reached if there is sufficient evidence to justify it.

Maughan, R v Senior Coroner for Oxfordshire V The Chief Coroner for England and Wales [2019] EWCA civ 809 Read the full report the Court of Appeal upheld the decision of the Divisional Court that in suicide cases the standard of proof for short form and narrative conclusions was the civil test of balance of probabilities not the criminal standard of beyond reasonable doubt.

Coroner Applications

HM Senior Coroner for West Sussex v Chief Constable of Sussex Police & Ors [2022] EWHC 215 (QB) – Coroner applied for disclosure of air accident documents. Application refused.

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