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.

R (Henshaw) v Assistant Coroner for Derby and Derbyshire [2025] EWHC 357 (Admin), 20 Feb 2025,  judgment here

As is often said, ‘when things go bad, they arrive in threes’.  And when three things do arise you really wouldn’t want them to be in a case which was already (as Mr Justice Jay remarked) “…a difficult case that would have challenged even the most experienced of coroners”:

However the bad tidings for the Assistant Coroner in these Judicial Review proceedings might helpfully allow other coroners to learn how:

• Not to direct a jury that they must first consider returning a traditional short form conclusion before returning any narrative;
• Not to overlook the decsion in Tainton[1] when dealing with admitted failings; and that
• If you do refuse to call a witness, make sure it is for the right reason.

What inquest lawyers should also note is that the approach of the High Court to re-running a complex inquest is grounded in pragmatism.  Even if three things do go wrong, one does not always a need to hold a fresh inquest to put them right. Here the jury directions had been unclear and the Claimant achieved a declaration validating two of her other complaints, but none of these slip-ups were significant enough to require the original inquest to be quashed.

Whittle v HM Coroner North West Wales [2025] EWHC 236 (Admin) judgment here

What were you doing on 24 November 1994? Can you describe the things you said or heard  that day or explain the rationale for any significant decision you made.   If I tell you that is the year Nelson Mandela was first elected president of South Africa, Kurt Cobain died and Forrest Gump was released does that help you at all?

On rare occasions a judgment of the High Court in an uncontested case will provide very little explanation of what has gone on to lead to the decision.   Yesterday a judgment was handed down in such a case.  Rather unsatisfyingly it is not really explained how or why the Senior Coroner here “encouraged”, the Claimant’s application to hold a fresh inquest into the death of a psychiatric patient so many decades after his first inquest ended, or perhaps more appositely, how the fresh inquest that has now been ordered can fully, frankly and fearlessly investigate this death, and compensate for  the inadequacies of the first, if there are now no medical records remaining, no witness statements, no details preserved of staff involved  in events and any witness still living will have to recall matters that occurred three decades ago.