Morrow v HM Assistant Coroner for Merseyside [2025] EWHC 935 (Admin) 15 April 2025 judgment here

What the bereaved hope might be investigated at an inquest and what the inquest actually explores are often very different things.    In this recent case the Assistant Coroner’s decision to draw a very tight investigatory scope was upheld by the Divisional Court.  There is no new law here.  Coroners have a wide discretion regarding scope and that discretion was properly exercised. The Coroner was entitled to have heard only limited evidence related to events very close to the time of death.

However there is still a lot to be learned from this case regarding how to avoid later conflict by bearing in mind the difficult position of an unrepresented bereaved family; seeking their views appropriately; managing their expectations by ensuring they fully understand the process;  providing them full explanations of why an inquest’s scope might be narrowly drawn along with the reasons for relevant coronial decisions. 

R (Robinson) v. HM Assistant Coroner Blackpool & Fylde [2025] EWHC 781 (Admin), 3 April 2025 (judgment here)

The ever the developing jurisprudence of Article 2 means that the categories of cases that can engage Art.2 obligations is not closed. However, in this recent decision Kerr J has firmly slammed the door in the face of Claimant who was proposing an extension of Art.2 into cases of misadventure occurring in police officers’ presence, saying that he “did not see any good reason to extend the existing categories of case in which article 2 applies automatically.”

The automatic Art.2 categories are considered automatic because the state will always need to explain how a death in specific circumstances came about: a paradigm example being where a suicide occurs in custody. But as the judge here recognised, it is not the mere fact of being in state custody that triggers the obligation. Cases of misadventure, even if occurring in police custody, are not apt to attract the automatic application of Art.2, because the misadventure may be unpredictable; the state agents may bear no blame for it; and it may require urgent medical attention beyond their expertise.

O’Brien v HM Assistant Coroner for Sefton, Knowsley and St Helens [2025] EWHC 362 (Admin) (heard in September 2024) the recently un-embargoed judgment is here

The Court of Appeal made the point resoundingly clear in Morahan[1] that “an inquest remains an inquisitorial and relatively summary process”.   As this latest case illustrates a Coroner may well be under a duty to seek out and record as many facts as the public interest requires, but this will not mean that the scope of an inquest must always be as wide as the Interested Persons might demand.   Rather, as the Master of the Rolls said in Dallaglio:

“It is for the coroner conducting an inquest to decide, on the facts of a given case at what point the chain of causation becomes too remote to form a proper part of his investigation. That question, potentially a very difficult question, is for him.”

The touchstone for the Scope of any inquest will be what was called in this case ‘Coronial Causation’, a term flowing from the decision in Tainton where the President had noted the difference between the threshold for causation of death and the standard of proof required to prove causation of death at an inquest.

The conduct or event must make an actual and material (that is more than minimal) contribution to the death. Depriving the deceased of an increased chance of life, or making their death more probable than it would otherwise have been will not be enough to satisfy the causation threshold for a coroner.

R (Gamesys Operations Ltd) v HM Senior Coroner Inner London South [2025] EWHC 659 (Admin) judgment here

The title of this blog will surprise no one, as it is already well established that a coroner has a very wide discretion regarding what evidence to call, including in respect of whether to seek expert evidence and from whom.[1]  There is nevertheless some helpful learning in this short ruling refusing the Claimants permission to challenge the Coroner’s choice of expert. Here the judge grapples with the unusual circumstances where there are some grounds for suggesting that a renowned expert may have a predetermined position on matters peripheral to the case.   It is helpfully explained how the “appearance of bias” test, that would apply to any judge or coroner, is not the correct approach in respect of an expert’s position.   An expert having previously expressed strident views on a matter will not necessarily bar them from acting in accordance with their duty of independence to the court.

Shipsey v Senior Coroner Worcestershire [2025] EWHC 605 (Admin) 14 March 2025 judgment here

“Hard cases make bad law”.  When that is one of the first things a Court of Appeal judge says as the case is opened before her you know it is going to be an interesting day in court.  But on reflection, perhaps the better aphorism here would be that “Hard cases make you think really very hard about the law in ways you have not needed to before”.  The outcome of the staggering procedural tangle generated by the manner in which this claim was brought has been an innovative legal resolution that has clarified the extent of the High Court’s s.13 powers.  What blog readers will now discover is that the remedies available to the court under s.13 Coroners Act 1988 extend further than you (and many others) previously may have thought.