R (Glaister & Carr) v HM Asst Coroner for North Wales. [2025] EWHC 167 (Admin) (here)

The decision whether and how to leave an unlawful killing conclusion for the jury in respect of a 16 year old falling from a mountainside on an explorer scout weekend overseen by volunteer scout leaders was always going to be both complicated and controversial.

When there needed to be a third go at holding the inquest – the first jury having been discharged after the court was misled, and the second inquest also being abandoned for material non-disclosure (with an IP later apologising to the bereaved in open court for its lack of sensitivity and the defensive stance it adopted), the writing may have already been on the wall that this case was rather extraordinary.

When you also learn that the inquest eventually involved 32 days of hearings, topped off by the coroner holding a court hearing on a Sunday to deal with legal submissions, before taking two days to deliver his summing up, handing 20 pages of written directions to the jury, then you may feel little surprise that this case ended up in the Admin Court for a second time challenging the conclusion. (For the first trip to the Admin Court see our earlier blog here)

The resultant judicial review decision will not disappoint those who love delving into legal complexity. Any coroner or inquest advocate grappling with applying the elements of gross negligence manslaughter in a coronial setting and who therefore needs to understand: (i) the Adamoko criteria[1] ; (ii)  the Broughton threshold[2] ; (iii) the Kuddus chance of risks[3] ;  and (iv) the Rose trap[4] (v) along with its ‘flags’, will certainly benefit from reading the first 38 pages of Fordham J’s decision it in its entirety.

The Chief Coroner, HHJ Alexia Durran, has today launched the “Chief Coroner’s Guidance for Coroners on the Bench” 

It has been produced as a resource for coroners to help them locate key principles, practical information and precedents when dealing with inquests, but of course will also be an invaluable reference point for all inquest practitioners.

As guidance it is not legally binding and does not replace the need for coroners and those appearing before them to conduct their own legal research. There will be times when the guidance is departed from for good reason. It holds the same status as the Chief Coroner’s existing guidance notes and law sheets, and has been issued to promote consistency and encourage best practice.

“In English law a person’s name is that by which he himself chooses to be known.”[1]

Despite Baroness Hale’s very clear statement it remains a surprise to some to learn that we have no ‘legal name’ under English and Welsh law. The identity of a person is not a matter of legal formality in that without any legal formality required anyone might reject the name they were given at birth, and that others have known them by, and adopt a new name.  A name appearing on one’s birth certificate does not create a ‘legal name’ for the simple reason that in this jurisdiction we do not have a ‘legal name’.

Of course most people do choose to retain and introduce themselves to others using the name given to them by their parents at birth, but there is no requirement to do so.  Any person aged over 16 may choose to adopt a new name at any time in their life for any reason, or for no reason at all.[2]

Families are therefore often surprised to learn that there is also no requirement in law for a deceased’s name as recorded and certified by the coroner at their death to correspond to the name that appears on their birth certificate.  As a judge of the High Court Chancery Division recently observed^[3] “there was nothing improper in allowing the deceased to be buried under the name which he had always used since he had lived in the UK. Although it was not the name which he had been born with.”   (Of course we are not actually ‘born with’ a name.  We are simply given a label by someone else shortly after our birth.)

Cherfan v Senior Coroner for West London [2024] EWHC 3261 (Admin). 12.12.24 Judgment here

It is a well establish principle that the costs of a successful Claimant’s judicial review case, or an application under s.13 Coroners Act 1988, brought against a Coroner will not be awarded unless particular circumstances arise.

As Brooke LJ noted in R (Davies (No 2)) v HM Coroner for Birmingham [2004] EWCA Civ 207, [2004] 1 WLR 2739 at §47,  the established practice is that where an inferior court or tribunal (including a Coroner) appears in the proceedings in order to assist the court neutrally on questions of jurisdiction, procedure, specialist case law and such like; the courts will treat the coroner as a neutral party. They will not make an order for costs against the coroner (or in the coroner’s favour) whatever the outcome of the application.

However, a Coroner who resists an application actively, introducing argument, such that they make themselves an active party to the litigation will, like any other Defendant, normally be ordered to foot the applicant’s bill if the Coroner’s arguments do not prevail (in accordance with CPR r. 44.2(2)).[1]

Relying on Davies the approach of many Coroners will be to remain neutral when their decisions are challenged.  However, to do so is no guarantee of costs protection. Where it is quite obvious that things have gone wrong, then a coroner who declines to consent to the application and simply sits back adopting a neutral stance may well have a costs order made against them, as this most recent case reveals.

Sammut and ors v Next Steps Mental Health Care & Greater Manchester Mental Health NHS Foundation Trust [2024] EWHC 2265 (KB), 2 September 2024. Judgment here

Anyone who thought the issue of the engagement of Article 2 and health care might now be settled after Maguire[1] was being over-optimistic.  There seem to remain a myriad of circumstance in which it is still argued that Article 2 obligations arise.

The Claimants in this civil claim for damages under Human Rights Act 1998 (‘HRA’) sought to rely upon an allegedly poor standard of health care in a private nursing home as engaging Art 2 obligations. However, as the judge found, the private organisation running the nursing home (Next Steps) was not a public authority under s.6 HRA and so owed no duty to uphold Convention rights.  Furthermore, the matter in issue was the quality of the medical care provided which, even if delivered negligently (as was alleged), would not have engaged any operational obligation owed to the deceased.

The judge made it clear, something going wrong or functioning badly as a result of clinical negligence should not be misconstrued as being due to systemic failures.  In the field of healthcare something far more exceptional, such as a knowing denial of life saving treatment, will be required. Bad clinical negligence, even to the extent of being reckless regarding a risk to life, will not suffice.