The Centre for Contemporary Coronial Law at the University of Bolton is pleased to announce that the previously successful short course on Inquest Law & Practice is to be repeated commencing on 13thJanuary 2022 via MS Teams

Consisting of seven evening sessions (1800 – 2030) at approximately two week intervals, led by experienced coroners, the course is aimed (inter alia) at advocates wishing to expand their work into the growing field of coronial law. The course will also be of use to people in a number of professions, particularly Coroners, Legal practitioners, Police, Coroner’s Officers, medical/health practitioners and medical examiners. The course has also proved useful for those wishing to take up coronial posts.  The lecture series is linked to CPD and totals 17.5 hours.

This professionally focussed programme is designed to develop knowledge and understanding of Coronial law through the delivery of an intellectually stimulating course, which is underpinned by research and practice. This Coronial Law Lecture Series is designed to introduce you to the law relating to Coronial Law and aims to help you demonstrate a critical awareness of the legal framework applicable to coroner inquests. You will learn how to evaluate, analyse and critically appraise appropriate legal rules in different coroner inquest situations.

Those interested in attending the Bolton Coronial Law Lecture Series 2022, should complete the registration form.The course fee can be paid for attending all seven sessions (£250) or for individual lectures (£45) as shown at the link below.

For any further questions contact (This email address is being protected from spambots. You need JavaScript enabled to view it.). 


Earl v Senior Coroner for East Sussex [2021] EWHC 3468 (Admin) 21 December 2021 here 

When 22 year-old Jessie Earl disappeared in 1980 it was inexplicable to her parents that this very happy, family loving art student would just walk away from her home, her studies and her life. The suggestion by a police officer that Jessie had somehow obtained another passport (hers was still at home) and left the country was, to say the least, fanciful.

Nine years later, when Jessie’s skeletal remains were found hidden in virtually inaccessible scrubland, it shouldn’t have taken Sherlock Holmes to work out that foul play was the highly likely explanation for Jessie’s disappearance. The cause of Jessie’s death was, by now, unascertainable, although there was some brown staining over the right temporo-parietal bone, which might have been blood staining. None of Jessie’s clothes or personal items were found, save for Jessie’s bra which had been tightly knotted and fashioned such that, in the opinion of the pathologist, 'both wrists of the individual may have been tied together by this brassiere'.

An expert in the craft of knots also reviewed the knotted bra and informed the police that it was similar to impromptu handcuff contrivances commonly found on victims at scenes of crime.  The knot was very tight and at some point had been subjected to considerable force. The tightening of the knot was not down to prolonged exposure. It was more likely the result of the knot being tied tightly, or subjected to struggling, or loaded with a weight (e.g. suspension or dragging). 

Despite all this evidence, the elementary deduction that this was a homicide somehow escaped both the police officer in charge of the investigation and the East Sussex Coroner. 

In the matter of an application by Margaret McQuillan for Judicial Review (Northern Ireland) (Nos 1, 2 and 3) [2021] UKSC 55,  judgment here

In the same week that Dominic Raab unveiled his proposals for a new Bill of Rights, Parliament’s intent when it enacted the existing human rights framework has also been the subject of scrutiny by the Supreme Court. In the matter of an application by Margaret McQuillan for Judicial Review, the Court has provided guidance on three key matters: the extent to which the investigative duty under articles 2/3 of the European Convention of Human Rights is engaged in pre-commencement deaths (the ‘Temporal Scope Issue’); when new evidence revives the investigative obligation (the ‘Brecknell Issue’); and how courts assess the independence of investigations (the ‘Independence Issue’).

Nguyen v Assistant Coroner Inner West London  [2021] EWHC 3354 (Admin) 10 Dec 2021 (judgment here)

Concerns raised about the adversarial nature of some inquest proceedings and the standards of advocacy displayed in Coroners’ Courts have led the Law Society and Bar Standards Board to recently issue new guidelines for all legal professionals practising in Coroners’ Courts. Those guidelines published in September 2021 (here) spell out the competences to be expected of lawyers by the regulators and the public. 

The Chief Coroner has the expectation that ‘coroners will be vigilant in ensuring those before them are meeting the expected standards’.[1]   Coroners will be encouraged to address practice that falls short of these competences either during the hearing itself or through raising their concerns with the relevant regulator.

It was not, however, the questioning style of the advocates that was called to account in this most recent application for a fresh inquest under s.13 Coroners Act.  Rather, the allegation was that the Assistant Coroner herself had overstepped the mark by raising unduly pressurising questions that at times amounted to speeches during her own assertive questioning of a key witness.  Her approach, the Claimant argued, had revealed an inappropriate ‘pro-doctor’ bias.[2]

In the view of the Divisional Court some of the questions raised by the Assistant Coroner were indeed “too assertive, [they] amounted to the setting out of propositions rather than questions, and/or involved several questions and not one, making it difficult for the witness to answer”.  Furthermore, some of the coroner’s remarks had been “unwise” and “close to being intemperate”.  

Although the Coroner’s approach did not justify a fresh inquest on the grounds of apparent bias alone, the Coroner’s manner of questioning of a witness was, however, “close to the borderline between robustness and unacceptability”.  As such it was one of the factors to be taken into account (alongside the emergence of fresh expert evidence that might call her conclusions into question) when the Divisional Court decided in the Claimant’s favour on the much broader question of whether, a new inquest should now be ordered as being desirable in the interests of justice.

Mays v HM Senior Coroner for Kingston Upon Hull & the East Riding of Yorkshire EWHC (Admin)  (1 December 2021)[1]

Witnesses often solemnly, sincerely and truly stumble over the words of the affirmation or oath.  Indeed many may wonder why it is that, when already feeling anxious at being placed in such an unfamiliar situation, they have to start the process of speaking out loud in a courtroom with such a tricky tongue twister.  But the witnesses’ vow is much more than some archaic linguistic formality. This solemn promise to tell the whole truth, and not just the parts you want to reveal, sits at the very heart of our coronial inquisitorial system. It is why it should be an obvious golden rule for every witness at every inquest that if you have any question at all in your mind whether or not you should tell the Coroner about some potentially relevant facts, then just speak up.  

The Coroner will be best placed to decide if something is or is not relevant and material to their investigation.  As this Divisional Court decision now underlines in red, asking other colleagues what to do and then following their misplaced advice that you need not reveal the full story to the Coroner, is unlikely to be the right course.

Dove v Assistant Coroner for Teesside [2021] EWHC 2511(Admin) 17 Sept 2021 here

This latest Divisional Court lesson on Article 2 ECHR not only provides a helpful summary excursion through the principles to apply when establishing whether the state’s obligations to protect life are engaged (or not) but it also takes the reader back to basics on the doctrine of precedent.

That another coroner elsewhere had determined that Art 2 rights were engaged in very similar circumstances to the present case was not helpful to the Divisional Court when considering whether Art 2 applied to the death now under consideration. The Claimant’s reference to an interim direction of the previous Chief Coroner in the Fishmongers Hall Inquests was also of no avail, given that decisions of earlier coroners are not binding on, or even persuasive, in the High Court. 

In Dove the Claimant drew the High Court's attention to an earlier decision by a different Assistant Coroner in a different part of the country to bolster the submission that the Assistant Coroner for Teesside had fallen into error. The Divisional Court was having none of it.  Mrs Justice Farbey made short shrift of such an approach, pointing out that it did not advance the Claimant’s submission one jot to put a series of conclusions reached by other coroners in a number of different inquests before the Court.  

The principle of stare decisis requires that all lower courts should make decisions consistent with previous decisions of higher courts - certainly not the other way round. The decisions of other coroners cannot be deployed to persuade the High Court (or even a fellow coroner in a different inquest) to tread a new path, rather than to follow established and binding case law on Article 2. When considering whether the state’s duty to protect life is engaged towards people who are not under state control (which was a key issue here) then application of the judgment of Supreme Court in Rabone [1] will be a far more fruitful place to focus attention.

Revised Chief Coroner’s Guidance 17: Conclusions here  & Revised Law Sheet No. 1: Unlawful Killing: here

As the consequences of the Supreme Court's decision in Maughan v HM Senior Coroner Oxfordshire [1] were contemplated in the coronial world,  the Chief Coroner promulgated specific legal guidance on how to tackle the new civil standard of proof for unlawful killing (see Law Sheet 6). However that January 2021 guidance has now been formally withdrawn and replaced with revised versions of the pre-existing guidance on narrative and short-form conclusions and an updated law sheet specific to the unlawful killing conclusion.  

Amendments were needed as before Maughan was determined it was generally understood that the criminal standard of proof applied to conclusions of suicide and unlawful killing.  As the Supreme Court in Maughan has made clear,  there is now only one standard of proof in inquests – the balance of probabilities.

R (Morahan) v HM Coroner for West London [2021] EWHC 1603 (Admin) 11.6.21 here

Arguments about the application of Article 2 ECHR remain one of the most taxing legal issues in the coronial jurisdiction.  That the European Convention was never intended to be applied as fixed black letter law, but to be an instrument open to judicial interpretation as views evolve as to what ‘Human Rights’ actually entail for the society of the day, means that the types of cases that might engage the Art 2 investigative obligations in coroners’ courts will never be fixed.   It is, therefore, unsurprising that cases exploring the engagement of Art 2 obligations in inquests seem to make their way to the High Court every six months or so, as one coroner or another ‘takes one for the team’ to help us all understand the current position in law.

Morahan is now the latest “cut out and keep” judgment for anyone wishing to get up to speed on the current state of the law with regard to Art 2 and the scope of the positive operational and the enhanced investigative Art 2 duties. In Morahan the Divisional Court has very helpfully examined Art 2 in detail, providing a summary guide to the recent key cases on Art 2 in the context of the death of a voluntary psychiatric in-patient from an accidental overdose when on approved leave from hospital.

R (Wandsworth) v HM Senior Coroner for Inner West London [2021] EWHC 801 (Admin) (here)

Most coroners won’t see any need to take extra care round a swimming pool when a Nicholas Cage film is about to be released, even given the clear relationship between one of Hollywood’s most prolific star’s film appearances and the number of people who die by drowning (see here). Nevertheless, in this recent Judicial Review case, the High Court have felt the need to remind coroners of the important principle in coronial law (sadly without any reference to Mr Cage) that correlation is not proof of causation.  

The fact someone lived in a place where asbestos was present was not sufficient to establish that their fatal mesothelioma was caused by inhaling fibres from that asbestos.   More is needed before a Coroner can be satisfied on the balance of probabilities, that a potential exposure to asbestos has more than minimally, negligibly or trivially contributed to a death.  That the deceased was possibly exposed to asbestos at a particular address, and that asbestos is very often the cause of the mesothelioma that killed them cannot justify an inquest conclusion that asbestos exposure caused the death.

Farrell v Senior Coroner North East Hampshire  [2021] EWHC 778 (Admin) 30.3.21 (judgment here)

In this strongly worded dismissal of a s.13 application the Divisional Court (including the new Chief Coroner) were perhaps signalling to Coroners that, whilst there may be an understandable wish to placate the bereaved,  detailed consideration should be given before lending one's support to an application for a fiat for a fresh inquest.  A fresh inquest cannot be justified simply to allay concerns of a member of the bereaved family, particularly where a reinvestigation would cause unwarranted distress to another.

When a family member raised suspicions of foul play – albeit with no real evidence in support - the Senior Coroner positively supported the application to the Attorney General for a fiat to apply to quash his documentary inquest into a mesothelioma death. [1]  That stance was likely to have been influential in the fiat being given.    

The Divisional Court have, however, now roundly dismissed the subsequent s.13 application on numerous grounds. Not only because of the lack of any evidence of the foul play being alleged, but importantly also noting that:

  • A fresh inquest would cause cost and delay to the coroner's service.
  • It would divert the health professionals involved away from their public service by requiring preparation for and attendance at a hearing.
  • The interests of justice do not require a family member be given a platform to air unjustified suspicions.