Is it the right body ? Coroners’ investigatory duties after inaccurate post-mortem reporting.

Written by: Bridget Dolan KC
Published: 12 September 2017

R (Heinonen and Sawko) v Senior Coroner for Inner South London [2017] EWHC 1803 (Admin)

It is often distressing for a bereaved family to contemplate their loved one being subject to a post-mortem examination, even in the context of a wish to have the cause of their death explained. When the resultant autopsy report contains an inaccurate physical description of the deceased, that thereafter remains unexplained, it is unsurprising that a family would seek further investigation of the matter by the Coroner.

However, in a case that provides a clear reminder of the high hurdle claimants must surmount to establish that a coroner’s decision is unreasonable (in the Wednesbury sense), the Administrative Court has upheld this Coroner’s refusal to open an investigation under s.1 CJA 2009, even though significant discrepancies between the description of the body examined and the deceased’s physical characteristics remained unexplained and further avenues that might have more firmly established the identity of the body had not been explored.

“I hope that an apology and some explanation as to how it came about will be forthcoming, I have no power so to order. I can merely express a hope that that will happen in due course”. – Andrews J

When giving Inquest evidence may cause distress to a vulnerable witness

Written by: Bridget Dolan KC
Published: 5 September 2017

R (Maguire) v Assistant Coroner West Yorkshire [2017] EWHC 2039 (Admin)

The horrific murder of Mrs Ann Maguire, a school teacher stabbed in her classroom by a 15 year old pupil, justifiably shocked the Nation. Now that William Cornick has pleaded guilty to her murder (and been sentenced to a minimum of 20 years’ detention) Mrs Maguire’s inquest will be resumed; but first the controversial issue of whether some of the school’s pupils tangentially caught up in the events should be called to give evidence at the inquest has had to be resolved.

“The distress of a young witness is not necessarily a reason why that witness cannot or should not give oral evidence.”

Following the murder some pupils had revealed in police interviews what they knew of Cornick’s actions in the period before the killing. These “interviewed pupils” reported how Cornick had at times behaved strangely, making morbid or sick jokes. He had expressed a wish to kill teachers and very shortly before the killing made specific statements about killing Mrs Maguire. Only one pupil had reported this behaviour to a teacher, but by then the murder had just been committed. Most of the other pupils did not take the threatening remarks seriously and so did not report them, assuming he was merely showing off. The one pupil who did take the threats seriously said nothing out of concern that if he did so it may provoke Cormick to attack him. After the killing that pupil had reflected “It’s like I could have stopped it. I did nothing.”

The Claimants (her widower and other members of Mrs Maguire’s family) wanted these “interviewed pupils” called so that the inquest could hear evidence as to the students’ understanding of the school rules relating to weapons in school and whistleblowing, and, for those who had taken no action, to explain why this was. The Claimants emphasised they did not seek to ascribe any blame or criticism to any pupil, but rather wished to minimise the risk of any similar horror occurring in the future. They wanted the inquest to explore lessons to be learned as to how children might be encouraged and supported to share concerns with trusted adults.

Self inflicted deaths in prison: “Something must be done” – but what?

Written by: Bridget Dolan KC
Published: 30 June 2017

R (Scarfe & Ors) v Governor HMP Woodhill & SoS Justice [2017] EWHC 1194 (Admin)

HMP Woodhill has achieved the unenviable status of having the highest rate and the highest number of self-inflicted deaths of any prison in the entire prison estate. Thirteen men have died there since 2013 at their own hand, seven of those in the last year. The eleven inquests that have recently been held in the Milton Keynes Coroner’s Court have produced several critical jury findings and a number of PFD[1] reports yet the alarming death rate has persisted.

It is unsurprising then that the families of some of the deceased, believing effective changes have not been made, turned to the High Court for action. They argued that the High Court should use its public law powers to ensure that the repeated failings noted in these successive cases were no longer tolerated.

The Woodhill Prison Governor and the Justice Secretary made it clear that they shared the great concern of the Claimants, the Court and other commentators (such as INQUEST who intervened in the proceedings) about the rate of suicides in prisons generally, and at HMP Woodhill in particular. The difficulty for the Claimants, however, was establishing the extent to which the identified problems at HMP Woodhill were capable of solution by means of their application for an order or declaration from the High Court.

Seeking Costs against Coroners

Written by: Bridget Dolan KC
Published: 19 June 2017

R (Gudanaviciene) v Immigration and Asylum First Tier Tribunal [2017] EWCA Civ 352

All humans make mistakes, Coroners included. Fortunately for any Coroner reading this, so long as you are merely human (and not flagrantly improper) and you don’t seek to defend your errors, then you should not be ordered to pay the successful applicant’s costs of reversing your poor judgment or bad decision-making.

The Court of Appeal considered whether a judicial body should be ordered to pay the costs of a successful application to judicially review its decision where it took no part in those judicial review proceedings.

Change the law to make Reports to Prevent Future Deaths work

Written by: Christopher Johnston KC
Published: 16 June 2017

The Grenfell Tower fire shows the need to give coroners’ recommendations more teeth.

On 28 March 2013 the coroner, after verdicts were returned on the deaths of six people in Lakanal House in 2009, made important and potential life saving recommendations (see for example her Letter to the Secretary of State for Communities and Local Government). These were made under then rule 43 – now the Coroners (Investigations) Regulations 2013 reg 28 and 29.

The government in over 4 years does not appear to have acted upon that report. Has the time not come to ensure that such vital recommendations are not ignored?

These coroner reports are usually made after an exhaustive review of the situation – and with the ability of all interested parties to make submissions. They are written after a review of the key issues undertaken with more forensic precision and over a far greater time than can usually be afforded by Parliament. Hence my “off the cuff” suggestion on Twitter that key coroner recommendations should be afforded a status akin to a negative statutory instrument: i.e. binding unless parliament overrules. This would force government to act and avoid life-saving issues being kicked into the long grass. In any event Parliament should act now to ensure coroners’ reports are not ignored in the future.