R (Silvera) v Senior Coroner Oxfordshire [2017] EWHC 2499 Admin. 20.10.17  (decision here)

Inquests play an essential role in ensuring public accountability when our hard pressed public services don't always manage to get things right.   That inquests allow for the full involvement of the family when publicly exploring the facts and coming to the understanding of what has happened is one of their most important features. The independence of the Coroner (or jury) when reviewing the circumstances of a death is crucial; as is the Coroner’s power to then notify any concerns to those who can take steps to make things safer for us all in the future.

Against that background it should, perhaps, not even need the added impetus of Art 2 ECHR to understand why some deaths are crying out for a publicly held independent investigation. Whilst the coronial jurisprudence around Art 2 ECHR and the investigative obligations that flow from it can be complex, it is hard for the outside observer to discern why the Senior Coroner in this present case was not even persuaded that Art 2 ECHR was engaged, let alone that an inquest was then required to satisfy the State’s investigatory obligations.  

The facts

The bare facts are that a woman, who all accepted was mentally unwell, had absconded from a psychiatric hospital by jumping out of a window just one day after the decision had been made to change her status to that of an informal patient (and so not continue with her detention under the Mental Health Act 1983).   The woman had also absconded the previous month, and at that time the staff had told police the woman was “very unwell” and “at risk of causing violence”. On this second occasion the police were again asked for assistance to return her to hospital and were told that the staff believed the patient “might do something” and “may be holding [her mother] hostage”. Yet she was nevertheless left in the community un-assessed for a further five days. At some point during that period she killed her mother.    

Engaging Art 2

Even a cursory reading of Rabone and Sargantson[1] would suggest it was at very least arguable that the state’s Art 2 obligations were engaged here, given the involvement of these two public bodies - and particularly as an internal NHS inquiry had already pointed to a number of shortcomings in the patient’s care and risk assessment.   Indeed the Chief Coroner, who gave the decision of the High Court, seems to have felt it was so abundantly clear that Art 2 was engaged that he didn't even bother wasting any space in his judgment explaining why![2]

The Senior Coroner, however, did not accept that Art 2 was engaged and further, even if it was, did not agree that resuming the inquest was required in the context of a guilty plea and the public bodies’ having already conducted their own investigations.

As the Chief Coroner has now made abundantly plain: where there has not already been an independent investigation of a death that has allowed for the proper involvement of the family and with a sufficient element of public scrutiny, then the inquest must be the vehicle to achieve this.

R (Dr Siddiqi and Dr Paeprer-Rohricht) v Asst. Coroner for East London.  Admin Court  CO/2892/2017 decision 28 Sept. 2017 (decision here)

Making a report that may prevent future deaths (a ‘PFD report’) under reg. 28 of the Coroners (Investigation) Regulations 2013 is an important but often misunderstood coronial power.

The issuing and receipt of a PFD report entails no more than the Coroner bringing some information regarding a public safety concern to the attention of the recipient. A PFD report is not punitive in nature, despite some interested persons construing it as such. It engages no civil or criminal right or obligation on the part of the recipient other than the obligation to respond to the report in writing within 56 days. The nature and content of that response is wholly a matter for the recipient.  In their response the recipient can choose to agree or disagree with matters within the report or rebut any determination of the facts that is expressed by the Coroner. The recipient can object to or accept the invitation within the PFD report to take action, and could even choose to respond by expressing the view that no action is required to allay the Coroner’s unwarranted concerns.

The appropriate remedy for those wishing to take issue with the content of a PFD report is to respond to the report.

 Against that background it is unsurprising that a recent attempt to Judicially Review a Coroner’s decision to issue a PFD report has fallen at the first hurdle

Re HM Senior Coroner for North West Wales (2017) EWHC (Admin) 4 October 2017 (no transcript yet available) 

When unidentified human remains were found on a Welsh beach in 1994 the cause of death was unascertained: the inquest returned an open verdict with the deceased unknown. However, tissue samples had been retained and advances in forensic science had recently allowed a DNA profile match to the brother of a woman who had disappeared in 1994. The circumstantial evidence strongly indicated that the deceased was his missing sister.

It must have been beyond question that these new facts and evidence made a further inquest that would now properly identify the deceased both necessary and desirable in the interests of justice.   The problem facing the Senior Coroner was that because an inquest had already been held the coroner was “functus officio” and had no power to quash the original inquest.

The cumbersome mechanism under s.13 Coroners Act 1988 for quashing a previous inquest now had to be followed to allow a fresh investigation to commence under s.1 CJA 2009. This involved the Coroner first making an application to the Attorney General, waiting for his authority to be given (under a fiat) before an application to the High Court under s.13(1)(b) could be made.

 Is it seriously considered that a Senior Coroner’s own application will ever be unmeritorious? 

It is no surprise that the A-G, followed by Lord Justice Treacy and Mr Justice Dingemans all readily agreed to a fresh inquest being held. Perhaps the only surprise is that it required a Divisional Court of two judges to consider the matter.

 This case is yet another example of time and money being unnecessarily spent before the obviously correct thing can be done. A s.13 application to the High Court can only be made “by or under the authority of the Attorney-General”. It is not unknown for obtaining that permission to take over 4 months in the most simple and clear of cases.

Permission stages in court applications, such as the fiat required here, are of course a good mechanism for weeding out frivolous, ill-founded or unmeritorious applications at an early stage. But is it seriously considered that a Senior Coroner’s own application will ever be unmeritorious?  The delay inherent in the fiat process merely extends the waiting for families and increases administrative costs for coroners.  The time must have come for revision of the legislation so that a Senior Coroner no longer needs the Attorney General’s permission to make a s.13 application.

R (Heinonen and Sawko) v Senior Coroner for Inner South London [2017] EWHC (Admin) 1803 (judgment here)

It is often distressing for a bereaved family to contemplate their loved one being subject to a post-mortem examination, even in the context of a wish to have the cause of their death explained.  When the resultant autopsy report contains an inaccurate physical description of the deceased, that thereafter remains unexplained, it is unsurprising that a family would seek further investigation of the matter by the Coroner.

However, in a case that provides a clear reminder of the high hurdle claimants must surmount to establish that a coroner’s decision is unreasonable (in the Wednesbury sense), the Administrative Court has upheld this Coroner’s refusal to open an investigation under s.1 CJA 2009, even though significant discrepancies between the description of the body examined and the deceased’s physical characteristics remained unexplained and further avenues that might have more firmly established the identity of the body had not been explored.

“I hope that an apology and some explanation as to how it came about will be forthcoming, I have no power so to order. I can merely express a hope that that will happen in due course”.   Andrews J

R (Maguire) v Assistant Coroner West Yorkshire [2017] EWHC 2039 (Admin) 14 August 2017 (judgment here)

The horrific murder of Mrs Ann Maguire, a school teacher stabbed in her classroom by a 15 year old pupil, justifiably shocked the Nation. Now that William Cornick has pleaded guilty to her murder (and been sentenced to a minimum of 20 years’ detention) Mrs Maguire’s inquest will be resumed; but first the controversial issue of whether some of the school’s pupils tangentially caught up in the events should be called to give evidence at the inquest has had to be resolved.

“The distress of a young witness is not necessarily a reason why that witness cannot or should not give oral evidence.”

Following the murder some pupils had revealed in police interviews what they knew of Cornick’s actions in the period before the killing. These “interviewed pupils” reported how Cornick had at times behaved strangely, making morbid or sick jokes. He had expressed a wish to kill teachers and very shortly before the killing made specific statements about killing Mrs Maguire. Only one pupil had reported this behaviour to a teacher, but by then the murder had just been committed. Most of the other pupils did not take the threatening remarks seriously and so did not report them, assuming he was merely showing off. The one pupil who did take the threats seriously said nothing out of concern that if he did so it may provoke Cormick to attack him. After the killing that pupil had reflected “It’s like I could have stopped it. I did nothing.”

The Claimants (her widower and other members of Mrs Maguire’s family) wanted these “interviewed pupils” called so that the inquest could hear evidence as to the students’ understanding of the school rules relating to weapons in school and whistleblowing, and, for those who had taken no action, to explain why this was. The Claimants emphasised they did not seek to ascribe any blame or criticism to any pupil, but rather wished to minimise the risk of any similar horror occurring in the future. They wanted the inquest to explore lessons to be learned as to how children might be encouraged and supported to share concerns with trusted adults.

His Honour Peter Rook QC has decided to hear the forthcoming inquest into the death of Sean Benton without a jury. Private Benton died from gunshot wounds at Deepcut Barracks in 1995, the first of four deaths at the barracks that have caused enduring public interest and led to numerous investigations. The original inquest, which took place only weeks after his death, was quashed by the High Court in 2016 and new hearings will begin in January 2018.

His Honour Peter Rook QC, formerly Senior Circuit Judge at the Old Bailey, was appointed as Nominated Coroner by the Lord Chief Justice. He was invited by the family of Sean Benton to exercise his discretion to hear the fresh inquest with a jury. His detailed reasons have been published and will be of interest to inquest practitioners, especially those working in military deaths and in cases likely to attract press coverage. They can be viewed here.

Bridget Dolan QC and Jamie Mathieson are instructed as Counsel to the inquest. John Beggs QC and Cecily White have been instructed for the inquest on behalf of Surrey Police, and Paul Spencer of Serjeants' Inn Chambers is instructed to represent a medical professional working at the barracks.