Procedural Notes from the ‘Birmingham Pub Bombings’ and ‘Deepcut’ Inquests

We all like a free helping hand, and so at the UKIL Blog we are happy to be able to share with the blogosphere the recent wisdom of two ‘Judge Coroners’ who have drawn up route maps to determining complicated procedural issues arising in their inquests.

None of what follows is formal guidance of course, but, practical tips from others’ experience are always useful, and coroners and inquest advocates might find these notes provide a helpful starting point when dealing with such matters, particularly when they have not, as yet, been addressed in the official ‘Chief Coroner’s Guidance’.[1]

R v Lawrence [2019] Wimbledon Magistrates Court

The unprecedented tale of “Dr.” Duncan Lawrence and his withholding of information from a coroner about his involvement in the death of the teenager Sophie Bennett has already gripped the headlines. This highly unusual criminal prosecution of a healthcare staff member who failed to give evidence at an inquest into the death of one of his patients is thought to be the first of its kind under the Coroners and Justice Act 2009 [1]. The saga has now taken a further extraordinary turn.

Despite having pleaded “100% guilty” on 16 August 2019, on subsequently attending court for sentencing Lawrence sought and was given an adjournment so that he may consider resiling from his earlier guilty plea.

The question that arises is whether, having already been fined £650 in May 2019 by the Assistant Coroner for his non-attendance at the inquest (pursuant to Schedule 6 part 6 CJA 2009), Lawrence is being put in double jeopardy by the additional criminal prosecution of him under Schedule 6 part 7 of the Act.

Frost v HM Coroner for West Yorkshire (Eastern District) [2019] EWHC 1100, 8 May 2019, (judgment here).

Where new evidence becomes available which renders an inquest’s factual basis inaccurate the interests of justice remain the touchstone for applications under section 13: even the passage of over half a century does not remove the necessity and desirability of ordering a fresh inquest.

Here a bereaved brother successfully applied to quash the decision of the Inquest held in 1966 (under the 1926 Act), which had found that Ian Spencer had murdered his 14 year old sister, Elsie Frost.  

Spencer had been committed for trial, but the Crown had offered no evidence against him.  A new investigation initiated in 2015 had implicated another man, Peter Pickering, who was already serving a life sentence for manslaughter of a 14 year old in 1972. However, Pickering died in 2018 before a charging decision could be made. The police twice publicly stated they believed he had killed Elsie.

The Coroner questioned the value of a fresh Inquest both in terms of the public interest and the interests of the families, and so left it to the bereaved family to go through the process of seeking a fiat and making an application for a fresh inquest.  The Divisional Court clearly did not share the Coroner's concerns.  Indeed, the judgment provides a handy 'nutshells' review of the issues relevant to the passage of time in an application under section 13, including the interests of the bereaved, of properly exploring deaths and of setting the record straight.   The issue of whether 53 years should render the further investigation into the tragic case unnecessary did not trouble the court, 

“Public interest has not been significantly vitiated by the lapse of time"

Re AB (Application for reporting restrictions: Inquest) [2019] EWHC 1668 (QB) 27.6.19 (judgment here)

When seeking any order it always helps to make the right application, to the right court, following the right procedure.   Although when it does go horribly wrong it at least provides valuable learning for the rest of us.

So make sure you are sitting comfortably, and get ready to be educated by Mr Justice Pepperall dishing out a lesson on making an application for reporting restrictions in respect of an inquest.

Inquest into the death of Geoff Gray, 20 June 2019 (Record of Inquest here and findings of fact here)

In what must be a coronial first an assistant coroner has issued a ‘PFD report’[1] directed at the Chief Coroner suggesting he may be able to take action himself to prevent future deaths by issuing guidance to coroners regarding post-mortem investigations after shooting cases.

On 20 June 2019 HH Peter Rook QC[2] concluded the second inquest into the death of Geoff Gray. Geoff was 17 years old when he died from two gunshot wounds to the head at Deepcut Barracks in Surrey in 2001.   Evidence heard at the fresh inquest revealed that very soon after Geoff’s body being found the assumption had been made by attending civilian and military police and by the coroner’s officer that Geoff’s death was a suicide. Therefore only a ‘routine’ coronial post-mortem was requested which was performed on the day of the death.

Two earlier deaths of young trainees from gunshot wounds [3] at the same barracks in 1995 were also both investigated with ‘routine’ coronial post-mortems. I[3]n one case the post-mortem had been carried out by a general histopathologist, who had no experience of performing an autopsy following a death from high velocity gunshot wounds.  

But, as the expert forensic pathologist in Geoff Gray’s case stated,

shooting cases are not routine”…“if you make assumptions early on in the investigation, then there is the likelihood, and indeed the probability, that vital evidential material is lost”.

Inquest into the death of Geoff Gray, 20 June 2019 (Record of Inquest here and findings of fact here)

The long running second inquest into the death of Private Geoff Gray at Deepcut Barracks ended yesterday when HH Peter Rook QC[1] returned a conclusion of suicide.

Geoff was only 17 years old when he was found dead from gunshot wounds in the grounds of the Officers’ Mess at approximately 01.10 hours on 17 September 2001. This fresh inquest, which was ordered by the High Court in 2017, had, in particular, explored whether Geoff had been shot by another person who had then moved his body to the location where it was found.

The Coroner held that Geoff, who had been on armed guard duty, had “died rapidly at the place where his body was found. No third party was involved in the shooting.

On the Record of Inquest the Coroner recorded that Geoff had shot himself with a SA80 rifle that was set to automatic, causing two wounds to the head, and that “at the time Geoff fired the shots he intended to take his own life, although that state of mind may have only been transient.” 

Questions had arisen as to how a young man who appeared as happy-go-lucky as Geoff could have carried out this fatal act. Particularly where, as the coroner found, “Geoff’s actions could not reasonably have been anticipated at the time. He did not suffer with any known psychological difficulties nor had he been the recipient of any ill treatment…Any concerns Geoff may have had did not relate to the camp regime.”

Having considered oral and written evidence from 105 witnesses, including 7 expert witnesses in pathology, ballistics and forensic science, the Coroner determined that Geoff had not been killed by another person.   “However the army had failed adequately to address the risk of self-harm that might arise in respect of young and inexperienced trainees performing guard duty with unsupervised access to firearms. Proposals that trainees should not provide the Barracks’ guard, but be replaced with a professional guard force had not yet been acted upon.”

“Whilst it was entirely Geoff’s decision to take his own life, the above failures provided Geoff with an opportunity to go to an isolated location with a firearm where he could act as he did.”

The Coroner also made a report to Prevent Future Deaths (a ‘PFD’ report) directed to the Chief Coroner and the Royal College of Pathologists. (see blog post here)


 The Coroner’s detailed ‘findings of fact’ will shortly be posted on this site when HH Peter Rook QC releases an approved transcript.


John Beggs QC and Cecily White of Serjeants’ Inn have represented the Surrey Police at each of the three fresh inquests into the deaths of trainees at Deepcut Barracks of Ptes Gray (in 2019), Benton (in 2018) and Ms James (in 2016). Bridget Dolan QC and Jamie Mathieson were appointed as Counsel to the Inquest.



[1] Sitting as an assistant coroner in Surrey

Ministry of Justice/ONS (9 May 2019 here)

One death is a tragedy; half a million – well, 541,627 to be precise – is a statistic. 

The Coroners Statistics Annual Bulletin 2018 (which covers the year to end of 2018) has just been released. It is, as always, an invaluable guide to the workload of coroners around the country and possible trends for the future.

The overall bad news is that more of us are dying. Total deaths reported to the ONS have risen year on year, from 484,367 in 2011.  The projected figure of 541,627 deaths in 2018 continues that trend and is set to be the highest total since 1999.

The coroners statistics of course only address those deaths a coroner needs to be told about (those thought to be violent, unnatural or unexplained or of someone in state detention): the good news is that there are less of those.

Of the several things to note in the latest figures the headline is that the removal of the requirement to report deaths of those subject to a Deprivation of Liberty Safeguard (‘DOLS’) authorisation has changed the statistical landscape.

The Professional Standards Authority for Health and Social Care v (1) NMC  (2) Anne Ndlovu   9 May 2019 EWHC 1181 (Admin)  judgment here

It is rare that healthcare staff are seriously dishonest in their evidence to an inquest, although sadly such conduct does at times happen.  Even when criminal prosecutions  are not subsequently pursued, this recent appeal is a strong reminder of the seriousness with which such conduct should be taken and the professional consequences for those who seek to dishonestly hide their errors.

 “Honesty, integrity and trustworthiness are ‘the bedrock’ of any nurse’s professional practice”.

As this case makes clear, courts will not look lightly upon dishonesty to a Coroner: it runs the risk of prejudicing an inquest which is flatly against the public interest.

R (Maughan) v Senior Coroner for Oxfordshire, the Chief Coroner as intervenor (and INQUEST as an interested party) [2019] EWCA Civ 809, 10 May 2019,  judgment here

After the seismic shift that followed Maughan in the Divisional Court it was remarkable that no one seemed to be predicting any aftershocks when the Court of Appeal considered the case.  After all, what had always seemed so obvious one way, was now just so obvious the other way once you stopped and thought about it.  Indeed, why on earth did any of us ever think that something that has not been a crime for more than half a century should require proof to a criminal standard within a civil inquisitorial jurisdiction?  

All the sensible money was on the Court of Appeal upholding the first instance decision.   They have not disappointed. Dismissing the appeal the CoA have now concluded that:

  • the civil standard of proof is to be applied to factual findings and determinations in inquests generally, including to findings of suicide (whether expressed in narrative or short-form conclusions);
  • the criminal standard of proof (exceptionally) applies to the unlawful killing conclusion. 

AB v Assistant Coroner for Inner South London   CO/663/2019, 1 May 2019 decision here.

The Extinction Rebellion protests are a forceful reminder, if any were needed, of how our planet is rapidly becoming more polluted with potentially worrying consequences for all who live on it.  Clean air is one of the most basic requirements of a healthy environment for us all to live, work, and bring up families.  As the government already acknowledges “Poor quality air is the largest environmental risk to public health in the UK” with exposure to nitrogen dioxide having an effect on mortality “equivalent to 23,500 deaths” every year.[1] 

When a nine year old girl dies from a severe asthma attack that may be linked to air pollution it is clearly a cause for concern and investigation.   

Ella Kissi-Debrah who lived alongside the busy London South Circular road died in February 2013 after suffering a severe asthma attack.  Ella had made 27 visits to hospital for asthma attacks since 2010. The first inquest into her death, held in 2014, focussed on the medical cause of her death and the medical care given in the short period between the fatal attack and her death.  The Assistant Coroner concluded that Ella suffered an asthma attack followed by a seizure and died after unsuccessful resuscitation. 

However new medical evidence was subsequently obtained that pointed to the severe air pollution in the area where Ella lived as having contributed to her death.  A monitoring station a mile from Ella’s home had repeatedly logged unlawful levels of air pollution. A Professor of immuno-pharmacology, who was an expert in respiratory disease, provided a report which concluded that the unlawful levels of air pollution had contributed to the cause and severity of Ella’s fatal asthma.  Further evidence pointed to an arguable failure by the state to regulate and reduce the extreme pollution that was implicated in her death.

“There was a real prospect that without unlawful levels of air pollution Ella would not have died”