The principle of open justice, allowing pubic scrutiny of how citizens come by their deaths, is at the core of the inquest process.  Save in exceptional circumstances[1] Inquests should be heard in open court with the media able to fully report the proceedings.

“The names of those who are born and those who die are rightly a matter of public record.  The fact that someone has died is always a matter of proper public interest and the ability to record it is a normal incident of society.”[2]

Readers will be familiar with Coroners’ powers under Section 39(1) of the Children and Young Persons Act 1933 to restrict reporting of the name of a child who is a witness or an IP. However Coroners have very limited alternative powers to protect the vulnerable who are not themselves an IP or  witness at the inquest.  

In exceptional cases, High Court judges have powers to make or extend a Reporting Restrictions Order (RRO) to protect others, such as family members of the deceased, from unwelcome press attention  (see earlier UK Inquest Law Blog post here re an RRO made in the Court of Protection in anticipation of an inquest).

However another often overlooked provision applicable to Coronial proceedings, and used effectively in a recent inquest, is Section 1 Sexual Offences (Amendment) Act 1992.

R (on the application of Secretary of State for Transport) (Claimant) v HM Senior Coroner for Norfolk (Defendant) & British Airline Pilots Association (Intervener) [2016] EWHC 2279 (Admin)


Readers of the UK Inquest Law Blog need no reminding that prior to the Coroners and Justice Act 2009, coroners had no power to order disclosure of any document so that if disclosure was required, an application had to be made to the High Court. The immediate point for the Divisional Court to decide in this case was the correct interpretation of the powers of coroners to require a person to produce documents (paragraph 2 of Schedule 5 of the 2009 Act). 

The involvement of the Lord Chief Justice indicates that there is a point of general importance.

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. 

Inquests often reveal matters that are of concern but which are unlikely to give rise to a risk of future deaths and so fall outside the reg. 28 “Report on Action to Prevent Future Deaths” provisions (the ‘PFD report’).  Yet it is often overlooked that where the duty to make a PFD report does not arise, the coroner still has another tool in their public health kit and may nevertheless draw attention to a matter of concern arising during the investigation by writing a letter expressing that concern to the relevant person or organisation who can act upon it. 

Known as a ‘Paragraph 37 Letter’ such a step is proposed and approved by the Chief Coroner at paragraph 37 of his Guidance No. 5 (Reports to Prevent Future Deaths); yet it is only rarely used. 

Ewing v Cardiff and Newport Crown Court [2016] EWHC 183 (Admin)

Bereaved friends and other members of the public often take notes of the evidence given in Coroner’s Courts.  Whilst Coroners can dictate much of the practice and procedure within their own courts, the recent case of Ewing in the criminal jurisdiction has clarified that it is only in very limited circumstances that restrictions should be placed on observers taking notes in public hearings and that no express permission to take notes is required.

“Although the Court may, for good reason, withdraw the liberty to take notes, the default position is that anyone who attends a public hearing is free to take notes.”