Inquest into the death of Geoff Gray, 20.6.2019 (Findings of fact)
In what must be a coronial first an assistant coroner has issued a ‘PFD report’[1] (available here) 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. In 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”.