R (Maxine Hamilton-Jackson) v HM Assistant Coroner for Mid Kent and Medway [2016] EWHC 1796 (Admin) (decision 19.7.16 here)


The absence of opening or closing speeches at inquests means that the need for clarity when summing up is all the more important. The jury must know clearly what they need to find as facts in order to justify any conclusion and, as the Chief Coroner has put it:

“Coroners, however well intentioned, should do their best in directing a jury to avoid using language which is not in everyday use, language which may not be clearly understood”. 

So what are an inquest jury to make of being told they need to decide whether or not there was a failure of a prison system or in the operation of a prison system, by “polarising the dichotomy between: is it mandatory to open an ACCT when a particular event occurs or is it mandatory to open an ACCT when the relevant official considers there is a risk of suicide or self-harm?”

Quashing the jury’s response to just one part of the jury questionnaire in this case, the Divisional Court has held that not only was there a misdirection, because the jury could not be clear what they were being asked to decide, but also re-iterated how the meaning of a policy is not a matter of fact to be determined by the jury, but is a question of law to be determined by the Coroner.

R (Tyrrell) v Senior Coroner for Durham & Darlington [2016] EWHC 1892 (Admin)  

(26.7.16 decision here)

 Around two thirds of the 250 deaths in prison each year are from a naturally occurring cause. In a decision that will be warmly welcomed by Coroners, the Divisional Court has now determined that there is no obligation to hold an Art 2 inquest into such deaths unless there are grounds to believe that there was some failure in the healthcare provided by the state.

This case in which the Claimant’s arguments were described as being advanced at a “high level of legal abstraction” is happily a victory for pragmatism and common sense.   

Were it otherwise Coroners would be obliged to conduct a large number of ‘Article 2 inquests’, to no discernable benefit of anyone and despite it being abundantly clear before the hearing that nothing untoward had taken place.

Burke-Monerville v HM Senior Coroner of Inner North London 

Application for urgent relief  High Court: Fri 8 July

The trend of recent decisions in the High Court has been a general reluctance to hear challenges to coroners' procedural decisions prior to the end of an inquest. Whether the proceedings have or have not been substantively or procedurally unfair is an issue that is best determined after the end of the hearing when the totality of the proceedings and the evidence can be considered.

It is unsurprising therefore that this urgent application for an injunction seeking to prevent an inquest going ahead on a Monday morning was refused in an extempore decision delivered at midnight on Friday.   

Bridget Dolan QC and Jamie Mathieson were counsel to the inquest into the death of Private Cheryl James in 1995 at Deepcut Barracks which ended on 3 June 2016.  The judge’s 100 page findings of fact, addressing the circumstances of the death and the culture and procedures at the camp, can be found here.

John Beggs QC and Cecily White acted for Surrey Police.  Paul Spencer of Serjeants' Inn Chambers also represented a medical witness at the hearings.

R (Tainton) v Senior Coroner for Preston and West Lancashire  [2016] EWHC 1396 (Admin) 16 June 2016


The Court of Appeal in Lewis* made it clear that there is a power, but not a duty, to leave to an inquest jury findings regarding non-causative shortcomings which only may have led to or hastened death.  A coroner has discretion to leave to the jury causes of death that are merely possible and not probable.  

However the Divisional Court have now taken an interesting side-step around Lewis by deciding that, in an Art 2 inquest where a shortcoming has been admitted then, even if it is only possibly causative of the death, the jury should be directed to record it.

“Where the possibility of a violation of the deceased’s right to life cannot be wholly excluded, section 5(1)(b) and 5(2) of the 2009 Act should require the inclusion in the Record of Inquest of any admitted failings forming part of the circumstances in which the deceased came by his death, which are given in evidence before the coroner, even if, on the balance of probabilities, the jury cannot properly find them causative of the death.”[74]

V v Associated Newspapers Ltd and others [2016] EWCOP 21

In November 2015 the Court of Protection determined that an adult woman had the mental capacity to decide whether or not to refuse the life preserving medical treatment offered to her.   She exercised her right to autonomy, refused treatment and died.    

Such capacity decisions are made on a regular basis in the Court of Protection (CoP) – however this particular decision in relation to ‘Ms C’1 has attracted perhaps more widespread media attention than any other Court of Protection case before it.  That reporting has been characterised by the Vice President, Charles J, as:

“reporting that engaged the prurient interest of the public in the personal details of the lives of others, rather than the public interest in important issues relating to [the court’s finding of capacity to decide and its consequences].”   

The back-story of Ms C’s life and her personality is clearly of the type that sells newspapers.  Ms C is now know to many as the “sparkling socialite” and pixelated pictures of her have appeared in both the broadsheet and tabloid press with epithets such as “man-eater” and “obsessed with sex” in the accompanying headlines.  

Reporting restrictions were, unremarkably, made at the time of the original CoP case. However, what makes this case unusual is the family’s subsequent application for the press injunction to be continued after Ms C’s death and to cover press reporting from her inquest.