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.


The principles of open justice and transparency are fundamental to our justice system. They must be cherished and protected as vital to preserve the rule of law.  However, a simple legislative oversight at the start of the pandemic has meant that, whilst most other courts increased their accessibility to the public by giving access via remote video platforms,[1] the Coroners Courts became more closed and secretive. All public, including accredited media representatives, have remained banned from watching any online broadcasts of coronial proceedings over the past twelve months.

This absurd position arose when the hastily passed Coronavirus Act 2020 made provision for four new sections to be inserted into the Courts Act 2003 which allow public participation in criminal, civil and family court hearings conducted by video link,[2] but unfortunately (confirming the view that Coroners Courts[3] are the forgotten relatives of the rest of the justice system) the broadcasting of coronial proceedings was overlooked and so wholly omitted from the Coronavirus Act 2020.[4]  

With a stroke this unintentional oversight has meant that for the past year neither the public nor accredited journalists have been able to watch any inquest proceedings unless they have been able to persuade a friendly coroner to let them walk into their socially distanced courtroom.   Happily, there have now been significant steps taken to correct this position via the Police, Crime, Sentencing and Courts Bill 2021.

R (Grice) v HM Senior Coroner of Brighton and Hove [2020] EWHC 3581 (here)

Will an inquest always be required after a homicide trial when there have been alleged failures by state agents to protect life?  In this Judicial Review case Garnham J gives us the answer by summarising the scope of the requirements of an effective Art 2 investigation and, particularly helpfully, setting out what is not required to satisfy the state’s the investigative obligation.

The Senior Coroner had refused to re-open the inquest into the murder of a woman by her former partner after her complaints of stalking were mishandled by police. There was no question that Art.2 was engaged on the basis of potential breach by the police of their operational duty to safeguard the victim’s life. Furthermore, the criminal trial alone had not satisfied the state’s Art.2 investigative duty.  However, the judge agreed with the Senior Coroner that the European Convention does not adopt a prescriptive approach to the form of the Art.2 investigation, so long as minimum standards are met.  One must look at the totality of the investigations conducted by the state whilst remembering that even the minimum requirements involve a degree of flexibility.

In this case the Art.2 obligation to conduct a prompt and effective independent inquiry with sufficient public scrutiny and sufficient involvement of the next of kin had been met by the combination of the criminal trial, a domestic homicide review and the three other investigations of police conduct. The Senior Coroner was not only entitled to find that these enquiries satisfied Art.2; she was right to do so.

In the matter of an Inquest into the death of Patrick McElhone [2021] NICoroner 1 (here)

The coronial world is still coming to terms with the impact of the Supreme Court decision in Maughan and what it will actually mean for inquests in practice. Even following the additional guidance from the Chief Coroner (here) the twittersphere still reverberates with questions such as how one can be ‘probably unlawfully killed’, whether how inquests are conducted will change if it is now open to return an unlawful killing conclusion in more circumstances, and whether Coroners will be open to judicial review if they fail to use those two words in a relevant case.

Some assistance with how to tread those difficult lines now comes from across the Irish Sea. The McElhone inquest provides a helpful example of how to frame what is (but for a semantic hair’s breadth) an unlawful killing finding within a narrative conclusion without needing to use those precise words.

Indeed, Mrs Justice Keegan has not only provided a tutorial on how to deal with factual findings in an unlawful killing inquest but she also more generally demonstrates how to tell the story of any death in a brief, concise yet comprehensive narrative.   Her verdict is so well worked that one doesn’t need to set out much of the background facts of the case here for the reader to understand what went on.

In the matter of the Inquest into the death of Michael Richard Vaughan [2020] EWHC 3670 (Admin) 16.12.20 (here)

Sometimes within the simplest of cases lies a wealth of useful reminders and lessons for everyone.   This superficially uncomplicated and uncontested application under s.13 Coroners Act 1988 is a treasure trove of learning for anyone who may find themselves seeking a fresh inquest.

The request for a fresh inquest here was well founded, and so one might expect the remedy to have been swiftly achieved.   The deceased had died after a self-administered paracetamol overdose and had left a note that provided evidence of his intent.  Unfortunately, that note was not put before the coroner: had it been her inquest conclusion of ‘misadventure’ would probably have been different.  But, despite the bereaved raising their concerns about the accuracy of the conclusion and the absence of the note on the day the inquest ended, it took more than five years before a fresh inquest was ordered by the High Court 

Chief Coroner’s Law Sheet #6,  13 January 2021 (here)

The new Chief Coroner, HHJ Teague QC, has just published his first legal guidance in the form of  “Law Sheet 6” addressing the impact of the case of R (on the application of Maughan) v Her Majesty’s Senior Coroner for Oxfordshire [2020] UKSC 46 on coronial practiceThese Law Sheets are written to assist coroners with the law and their legal duties, and to provide commentary and advice on policy and practice.

On 13 November 2020 the Supreme Court determined in Maughan that the civil standard of proof is to be applied in coronial inquests for all conclusions that a coroner or a coroner’s jury might return, including unlawful killing. (See our earlier blogs (here and here.) Previously it had been accepted that the ‘short form’ conclusions of unlawful killing and suicide could only be returned if found proven to the criminal standard of ‘beyond reasonable doubt’. However, the Supreme Court brought coronial law into line with a number of other areas of civil law when it held that, as a matter of common law principle, the criminal standard should not apply to any conclusion in coronial proceedings.

Setting that change in its wider context, in 2019 there were fewer than 166 conclusions of unlawful killing made by coroners or juries in inquests, this was half a percent of the 31,284 inquests concluded.  The issue of unlawful killing is likely to feature in relatively few inquest cases. However, when it does arise it will of course be of substantial importance to all involved.

 R (Maughan) v Senior Coroner for Oxfordshire [2020] UKSC 46 (here)

There is perhaps no better example of the judicial development of our common law than Maughan. A case which began with a family member appealing against what they believed was the incorrect application of the civil standard of proof to a suicide conclusion has ended with the Supreme Court determining that not only was the standard of proof correctly applied in circumstances where suicide is a civil finding, but that the same logic also applies to an inquest conclusion of unlawful killing.

There is to be only one standard of proof in inquests and that is proof that the fact in issue more probably occurred than not.

This will no doubt surprise many readers, and perhaps rightly so, as the decision in Maughan is from a divided court: a 3:2 majority concluded that the standard of proof for all conclusions at an inquest  – including ‘suicide’ and ‘unlawful killing’ – should be the civil standard.

Although as one of the dissenting voices, Lord Kerr, has quite rightly emphasised in another setting:[1] the importance of dissent, even when in the final court of appeal, is that it contributes to the transparency of the debate, and far from detracting from the authority of the majority opinion, that opinion, in confronting and disposing of an opposite view, if it has been done convincingly, will be all the more commanding of acceptance as a result.

Chief Constable West Yorks Police v Dyer & Assistant Coroner for West Yorkshire & others [2020] EWCA Civ 1375, 27 October 2020.  Judgment here

Judicial endorsement that Black Lives Matter sends an important message to all.    Whilst our British judges might never be expected to deliver as hard hitting and politicised a judgment as that handed down by the wonderful US District Judge, Carlton W. Reeves, this August in Jamison v McClendon (here) -  which for this blogger comes top of the list of the most powerful first 20 lines of any court's judgment this millennium - the recent decision from the Court of Appeal in Dyer nevertheless sends a clear signal that the racial background of a person who dies after contact with the police can matter when open justice is in issue.

Specifically, the appellate court has determined that when the Coroners Rules require a coroner to consider the test of ‘expediently’ this is to equated with ‘appropriately’ and should include considerations of the wider interests of justice.   For one of the three Lord Justices of Appeal a relevant factor in considering those wider interests can be that the person whose death is being inquired into was a black man who died in the custody of the police.

Rushbrooke v HM Coroner for West London [2020] EWHC 1612 (Admin) 23.6.20. judgment here

With such a huge backlog of inquest cases waiting to be heard and the difficulties of convening inside a courtroom during the current pandemic, the appeal of holding a swifter, documentary only inquest is plain to see.  However, the recent case of Rushbrooke is a timely reminder to coroners that they will run the risk of their findings being quashed if the haste to hold a paper-based inquest results in an insufficient investigation.

R (Skelton) v Senior Coroner for West Sussex and the Chief Constable of Sussex Police & Robert Trigg (interested parties) [2020] EWHC 2813 (Admin)  , 23.10.20 Judgment here

Determining whether Art 2 procedural obligations are engaged at an inquest can be one of the most challenging legal questions in the coronial jurisdiction.  The issue for a coroner is not whether breaches of a substantive Art 2 duty have been made out, but whether such breaches are “arguable”. 

The Divisional Court have made it clear that, when considering arguability, coroners should apply the test in Maguire,[1] asking themselves whether there is a ‘credible suggestion’ that a breach of substantive Art 2 rights may be established after the further and fuller investigation of all the evidence which will be available at a Middleton inquest

Further, should a coroner’s decision be challenged with unqualified human rights in play, the Divisional Court’s role is not to assess the quality of the decision on pure public law grounds but to apply heightened scrutiny, effectively asking itself the same question that the coroner has considered.  Hence in practical terms there can only be one right answer and a rationality challenge collapses into a merits review.

R (Skelton) v Senior Coroner for West Sussex and the Chief Constable of Sussex Police & Robert Trigg (interested parties) [2020] EWHC 2813 (Admin),   23.10.20 Judgment here

Whilst many will be unsurprised to be told that a fresh inquest cannot reach a verdict inconsistent with an earlier homicide conviction, it is nevertheless reassuring to learn that a statutory lacuna on this issue has now been firmly filled by the Divisional Court in this recent case.

The relevant part of the CJA 2009 clearly states that if an inquest is suspended and later resumed after a homicide conviction the conclusion of the inquest may not be inconsistent with the criminal jury’s determination. This recent challenge arose in the context of a situation not addressed in the statute: where a wholly fresh inquest was to be held.

Greater Manchester Fire and Rescue Service v Veevers [2020] EWHC 2550 (Comm) 25.9.20 - Judgment here

 Can a family’s inquest costs be recovered in a subsequent civil claim if an admission has been made prior to the inquest? If the admission has in fact been informal or equivocal, the answer may well be yes.

The Background

This claim arose from the tragic death of Mrs Veevers’ son, a firefighter, who died in a fire of 2013 from hypoxia and heat exhaustion. Around two months before an inquest was due to begin in 2016, and after the family representatives had already undertaken ‘extensive investigations’, the solicitors for the fire service wrote to their counterparts for Mrs Veevers, setting out:

Our clients have made no assessment of the potential for liability to the estate and dependants of (the deceased) but they have instructed us to set out their position in relation to any potential claim which may be brought for the family…Our clients are not in a position to consider an admission of liability and we have not undertaken a detailed forensic analysis of the potential for liability in any civil claim on their behalf. The purpose and objective in making the comments which we make directly below is to attempt to remove any additional stress from the family during and immediately after the inquest…We write in open correspondence in order to advise that our clients are willing to compensate the estate and dependents of Stephen Hunt pursuant to the Fatal Accidents Act 1976 and Law Reform (Miscellaneous Provisions) Act 1934, for any loss which they may prove to be attributable to the incident on 13 July 2013 together with payment of their reasonable costs.’

The six-week inquest was heard with a jury who returned a conclusion of unlawful killing, the jury finding the fire was probably started deliberately.[1] Civil proceedings were subsequently issued and it was admitted that the fire service were liable for failing to ensure the deceased did not exceed the maximum time using breathing apparatus and PPE. The fire service also agreed to pay Mrs Veevers’ reasonable costs. Her total costs bill was £334,000. She sought recovery of the costs incurred by her legal representatives preparing for and attending the inquest, which amounted to £141,000, over 40% of all of her costs.

Chief Coroner’s Guidance No. 37 - "COVID-19 Deaths and Possible Exposure in the Workplace "  amended on 1st July (here)

It is not often that guidance from the Chief Coroner excites the twittersphere.  But the original version of this Guidance #37, issued on 28 April (see our earlier blog here), managed to generate much comment from the public, Doctor’s Associations (here) and even MPs regarding the approach to considering shortcomings in the provision of PPE. The Chief Coroner puts out guidance, he does not make statements of policy. Some seem to have even misunderstood his guidance to be advocating that healthcare workers’ deaths should not be referred to a coroner.[1]. Nevertheless, many commentators will feel vindicated in that the Chief Coroner has now updated his earlier Guidance which now focuses more on the individual judicial discretion of each coroner.

Re Ketcher and Mitchell, [2020] NICA 31 (judgment here) 3 June 2020.

There has rightly been increasing emphasis since the Mid Staffs inquiry and other high media profile investigations, such as Hillsborough, on the responsibility of public bodies to be open and candid in all of their dealings with the Coroner.  Whilst legislation falls short of imposing a statutory duty of candour in respect of inquests, the expectation many will have of our public bodies is that they will do all they can to assist the coronial investigation in ascertaining the truth of how a person came to die, regardless of any reputational consequences or fear of future litigation.  Indeed the Ministry of Justice has recently published the Government's protocol that sets out the principles it expects to guide the behaviour of Government Legal Department lawyers and those they instruct at inquests. This includes an exhortation to "approach the inquest with openness and honesty, including supporting the disclosure of all relevant and disclosable information to the coroner" which they suggest should be a 'model of behaviour' for all interested persons. (see here at Annexe A)

Against that background this recent decision from the Northern Irish Court of Appeal may seem rather out of kilter with the laudable aim of openness.  Although expert evidence obtained solely for the purpose of an inquest will not, say the NI CA, attract litigation privilege, any compulsion to disclose such a report will, in the view of the Court, be highly likely to be unreasonable as being contrary to the public interest in encouraging interested persons to investigate and prepare their own cases. 

Notably however, the context here was an expert report obtained on behalf the bereaved families in an Art 2 inquest – it is more difficult predict whether,  if it were a public body seeking to supress relevant evidence in an Art 2 inquest, the public interest balance would still be drawn in the same place.

R (on the application of Maguire) v HM Senior Coroner for Blackpool & Fylde [2020] EWCA Civ 738. (judgment here)

The Court of Appeal has ruled that the state's investigative obligations under Article 2 ECHR do not arise where someone lacking capacity and deprived of their liberty dies of natural causes.The state’s obligations under Article 2 had not been triggered in this case by the mere fact of vulnerability and that the deceased was deprived of her liberty in a care home pursuant to a standard authorisation under DOLS  [1].


Jackie, who had Down’s syndrome and learning disabilities, and so was unable to care for herself, had fallen ill at her care home in the days before her death.  The care home provided only personal (not medical) care but, when Jackie’s condition worsened, she had refused to go to hospital and had been permitted to remain at the home overnight.  Jackie’s condition worsened further and she was eventually taken to hospital where she died as a result of a perforated gastric ulcer, peritonitis and pneumonia.  At her inquest her family criticised (inter alia) the lack of a protocol at the care home for admitting Jackie to hospital in spite of her refusal.  However, the Coroner ruled at the close of evidence that Article 2 ECHR was not engaged, such that the “how” question for the jury to answer under section 5(2) of the Coroners & Justice Act 2009 had its narrower meaning of “by what means” instead of “by what means and in what circumstances”. 

The jury who were not permitted to consider any failings on the part of those caring for Jackie returned a conclusion of natural causes. Jackie's mother sought judicial review of the coroner's decision, when that application failed she appealed. 


On the 11th June 2020, The Chief Coroner published his Guidance No 38, headed ‘Remote Participation in Coronial Proceedings via Video and Audio Broadcast’. (here)

Just as the Crown Courts start to address the difficult issue of holding jury trials once more, so the Chief Coroner has sought to encourage Coroners, Practitioners, Interested Persons, Witnesses, the Press and Public as to how Inquests can or may be held as the lockdown is released, albeit gradually, and with social distancing maintained.

The current pandemic has increased the need to use technology to facilitate remote participation in hearings. Whilst it is the Chief Coroner’s view that partially remote hearings should take place wherever possible if the technology allows, it is in the interests of justice and its use must be consistent with the administration of justice.

A Coroner must be physically present in Court to hold an Inquest

It may come as a surprise to everyone to learn that, unlike judges sitting in civil and criminal jurisdictions, Coroners must be physically present in a Courtroom to hold an Inquest. Civil and Criminal judges have been able to hold remote hearings from their kitchens, attics and even gardens during the pandemic but nothing can be conducted by a Coroner acting remotely from their office or home.

If a Coroner has to be physically present in Court to hold an Inquest, who else does?  Can there be a mix and match or as the current phrase in Coronial Circles gains traction, has the Chief Coroner heralded the start of ‘Harlequin Inquests?’ [1]

“Doctor, cast the water of my land, find her disease, and purge it to a sound and pristine health…” Macbeth, Act V, Scene III


The difference between the Scottish and English approaches to managing coronavirus appears to be growing. Guidance from the Chief Coroner for England and Wales, HHJ Mark Lucraft QC, indicates that unless there are other factors, deaths caused by or suspected as being caused coronavirus don’t need to be reported to coroners; and deaths from coronavirus contracted in the workplace “may” be reported to the Coroner, but not necessarily resulting in an investigation. 

By stark contrast, Scotland’s Lord Advocate, Sir James Wolffe QC, has announced (here) that all confirmed or presumed COVID-19 deaths of residents in care homes or people who may have contracted the virus in the course of their work will be investigated by the Crown Office. The reasons for this difference of approach appear to lie in the different statutory remit of each office (Scotland doesn’t have inquests or coroners). However, the outcome might strike many as resulting in an arbitrary postcode lottery.

Ministry of Justice/ONS (14 May 2020) here

On 14 May 2020, the most recent Coroners Statistics Annual Bulletin was published. At a time when data on death dominates the news, the Bulletin may have passed inquest practitioners by. However, the Bulletin remains a useful guide on the workload of coroners around the country and can be used to identify possible trends for the future.

It is important to note that whilst the Bulletin was published in May 2020, it covers the period from January to December 2019 and therefore it does not cover any Covid-19 related deaths. Such deaths will not be included in the Bulletin until its next publication date in May 2021.

Key figures from the 2019 Bulletin:

  • 40% of all registered deaths were reported to coroners in 2019;
  • Overall deaths in state detention are down 7%, driven largely by a 16% fall in deaths of individuals under the Mental Health Act 1983;
  • Overall, conclusions of suicide increased by 11%;
  • Average time taken to process an inquest rises to 27 weeks.

CHIEF CORONER’S GUIDANCE No. 37. 28 April 2020 here

The Chief Coroner has today released his further guidance to coroners during the COVID-19 pandemic.  The Chief Coroner sets out when a report to a coroner must be made and when an inquest will and will not be required into a death from what is a naturally occurring disease.  

He also puts a shot across the bows of anyone who thinks that these future inquests will be the right forum for examining high level decisions about the supply and provision of PPE to our front line health care workers and care staff: 

“An inquest is not the right forum for addressing concerns about high-level government or public policy”.   

The key points of the Chief's Guidance are set out below:

R (Carole Smith) v HM Assistant Coroner for North West Wales [2020] EWHC 781 (Admin) (judgment here) 7 April 2020.

The High Court has emphatically supported a Coroner’s decision not to record admitted, non-causative failings in an Article 2 inquest conclusion. The court’s observations about the proper content of a Record of Inquest (ROI) will be thought-provoking for all Coroners and practitioners particularly as they (i) imply judgmental conclusions on the ROI may be inappropriate (ii) narrow the import of the Tainton decision to jury cases and (iii) elevate the Coroner’s findings of fact and pre-conclusion reasoning to a level that may have significant repercussions for how Coroners close their proceedings in future.

The steep increase in the number of deaths occurring outside hospital during the Covid-19 pandemic brings a concomitant rise in the number of deaths requiring verification in the community.

Attending those who have died in the community clearly puts health care workers at increased risk of Covid-19 infection themselves.  In response the NHS has put out guidance (here) suggesting that GPs or another suitably qualified health care professional might now verify death remotely by video, or even by telephone, if family members are happy to support that verification process by, for example, reporting down the phone the absence of movement of the chest wall.

Unsurprisingly that guidance (also now promulgated by other organisations)[1]  has resulted in many calls to coroners and the ambulance service (particularly in London) from GPs and funeral directors who want clarification about the rules or advice about how to pronounce life extinct.

In response, London’s Senior Coroners, who have reservations about the NHS Guidance, have today produced a four-page document (here) setting out their agreed view of the death verification requirements, for the benefit of affected people in the London Area. They acknowledge that different approaches are being taken elsewhere. [2]

The Chief Coroner's Guidance on COVID-19

The Chief Coroner's Guidance on COVID-19 (No.34) here was issued on 26 March 2020 and reinforced on 27 March 2020 with further guidance (No.35) here. It is helpful to be read in conjunction with the Chief Coroner’s COVID-19 Note #3 here. It is intended to be the main piece of guidance for all coroners.

The message overall is that coroners have discretion and judgement to exercise in various respects, which they can be expected to exercise in a pragmatic way taking account of the effects of the pandemic.

However, it also makes clear that a Coroner’s Court should be open for “urgent and essential business only” and further, “absent a coroner a court is not a court”.

The reinforcement of this latter aspect tends to suggest approaches have been made to the Chief Coroner, following his Guidance no34, questioning the need for a coroner to be physically present in a Coroner's Court in order to conduct a hearing.

The response is a clear and unequivocal … yes.

The Bishop of St Albans, Dr Alan Smith has introduced a Bill aimed at using the coronial system to record where gambling addiction has contributed to suicide.

If the Coroners (Determination of Suicide) Bill [HL] (HL Bill 32) is passed, then where the inquest's conclusion is suicide, the coroner or jury will be required to record an opinion “as to any factors which were relevant to the death[1]

The one factor which the coroner or jury must consider under the proposals is whether the deceased had an addiction to gambling, no other specific factors are identified.[2]

Dr Smith is motivated in bringing forth the Bill having “met far too many families whose lives have been destroyed by the loss of a loved one, often young adults who have their entire lives ahead of them.” Indeed, a quick web search for “gambling” and “suicide” reveals pages of search results detailing a litany of tragic deaths, mostly of young men.

R (Lewis) v Senior Coroner for North West Kent [2020] EWHC (12 February 2020) judgment here

A coroner who chooses not to give reasons for a controversial decision may as well hand the aggrieved interested person their acknowledgement of service for the forthcoming judicial review claim along with the record of inquest.   Giving reasons is a fundamental aspect of judicial decision making: the person losing an argument in court is entitled to know not only that he has lost but why.

In this case a psychiatrically unwell patient detained in a forensic secure unit had died from malnutrition. The senior coroner refused to leave neglect to a jury without giving any reasons for deciding not to do so.  The senior coroner’s decision was flawed on two counts: not only due to an absence of reasons, but, as the Divisional Court found, because it was also not reasonable on the evidence to fail to leave a finding of neglect open to the jury in the “somewhat disconcerting” circumstances of the case.

Namiq v Manchester University NHS Foundation Trust  [2020] EWCA (14.2.20) judgment here

Readers of this blogger's generation will already know that the answer to the Meaning of Life is 42.  The Court of Appeal have now addressed a question too momentous for even Douglas Adams to tackle - what is the meaning of death? [1]

Last month in Manchester University NHS FT v Midrar Namiq (a minor) and others, [2020] EWHC 6 (Fam) here Lieven J was asked to consider the heart-rending issue of whether ventilation should be withdrawn from a severely brain injured baby. (see our related blog here).

The Supreme Court had already confirmed in a number of appeals (including those launched on behalf of both Charlie Gard and Alfie Evans), that the Judge must apply the best interests tests in serious medical treatment cases.  However, here the Trust’s position was that the child was in fact already dead and that there can be no best interests assessment of a person who is no longer legally alive.   Hence, said the Trust, the Court’s function in Midrar’s case was to assess whether the relevant clinical testing had established that he was brain stem dead.   In contrast, in addition to arguing that the brain stem testing had not been properly carried out, Midrar’s parents argued that the Court’s role was to apply the best interests test to the question of whether the intensive care support that was still keeping oxygenated blood circulating his body should be removed.

One difficulty was that, despite clinicians and paramedics regularly declaring life to be extinct, there is no legal definition of death in any statute.  Death is clinically and not legally defined.  Although the common law position was considered in 1993 when the House of Lords reviewed the position of Tony Bland who had been in PVS for three years after being caught in the Hillsborough crush. Although Tony Bland had no consciousness his brain stem was still functioning, which controlled his heartbeat, breathing and digestion, and as such, said their Lordships, he was not dead.  Indeed, the medical consensus that death was to be diagnosed by an absence of brain stem function was expressly endorsed in Bland[2]

R (Lee) v HM Assistant Coroner for Sunderland [2019] EWHC 3227 (Admin) 12.9.19 (judgment here)

Regular readers of our blog will recall this case dealing with the tricky issue of whether Art 2 obligations are engaged when a person dies whilst receiving psychiatric care in the community. (See the earlier blog here)

In Lee v HM Assistant Coroner for Sunderland HHJ Raeside QC produced a complex extempore judgement that provided the very simple answer: you need look no further than Lord Dyson's explanation at paragraph 34 of Rabone, when he analysed the potential engagement of the operational Art 2 duty by reference to the threefold factors of assumed responsibility, vulnerability and risk

However the judge deftly sidestepped answering the question on the particular facts of the case before him and instead remitted the case back to the coroner to decide.  HM Assistant Coroner for Sunderland has now had a second bite at the cherry and produced an elegant set of reasons for her finding again that Art 2 was not engaged.  Although, as a decision by a coroner, the reasoning has no precedential weight, those reasons attached here are well worth reading for their detailed exposition of the application of Art 2 to inquests and a clear example of how to apply the indicia in Rabone to the facts of a particular case.





Jordan v The Chief Constable of the PSNI [2019] NICA 61.  15 November 2019 (judgment here)

The latest instalment of the long running Pearse Jordan inquest saga provides an important warning to all coroners and other public bodies involved in Article 2 investigations where there is delay in coming to inquest because of shortcomings on the part of a public body (including the court).

Mr Jordan’s family have now had their second award of damages upheld by the Northern Irish Court of Appeal. The appeal court found that a sum of £5,000 represented ‘just satisfaction’ for the exacerbation of the bereaved’s ‘feelings of frustration, anxiety and distress’ arising from 14 months of culpable delay in bringing the case to inquest.   This assessment of damages took into account that an award of £10,000 had already been made by the European Court of Human Rights in 2001 as compensation for earlier delays in investigating Mr Jordan's death.

R (Lee) v HM Assistant Coroner for Sunderland [2019] EWHC 3227 (Admin) 12.9.19 (judgment here)

It is now commonplace in advance of inquests for coroners to rule on their scope, including whether possible state responsibility requires the inquest to meet the UK’s Art 2 procedural obligations. That task is not easy when the extent of Art 2 involves a complex question of law to be applied in factual circumstances that are often still to be uncovered. Added to that, the jurisprudence of the Art 2 duty is still evolving as its boundaries are repeatedly explored by the courts as new circumstances are presented for consideration.

The case of Rabone v Pennine Care NHS Trust[1] was one such new circumstance and considered whether there was an operational duty owed under Article 2 to informal psychiatric in-patients who were not detained under the Mental Health Act. Although Melanie Rabone died when on leave outside of hospital the Supreme Court considered that the operational duties did extend to the circumstances of her case - taking account of her extreme vulnerability and the exceptional nature of the risks alongside the degree of responsibility and control assumed by the NHS Trust.

Following Rabone the question arises of whether Article 2 procedural obligations might be engaged after the death of a person who is a mental health patient receiving care in the community.   In this blogger’s experience several coroners (and NHS Trusts facing civil claims) have since accepted that an Art 2 duty can be owed to a community patient, particularly where the alleged shortcomings include a failure to admit a vulnerable person who was at obvious and imminent risk of suicide. However until recently no challenge to a coronial decision on the application (or non-application) of Art 2 at a community patient’s inquest has been reported from the higher courts.

The applicant in R (Lee) v HM Assistant Coroner for Sunderland has now invited an important extension of the law beyond Rabone. However, if you are hoping for clear or simple answer to this vexed question be ready for disappointment. To paraphrase this very lengthy extempore judgment - delivered by HHJ Raeside QC after hearing two days of legal argument –  it is all very complicated and will always depend on the facts.

Dyer v Assistant Coroner for West Yorkshire [2019] EWHC 2897 (Admin) 30 October 2019 (judgment here)

If the tribunal, the lawyers and the jury who will be making the decision can watch a witness as they give live evidence one might ask why should it matter if the rest of the public and press might not see the witness' face?

However it matters a great deal if one is to have any respect for the constitutional principle of open justice which, as one of the core safeguards in our judicial system, should be fundamental to all courts and tribunals exercising the judicial power of the state.

In Coroners courts, as in the rest of the British justice system, the notion that justice should not just be done, but also be seen to be done is far more than an often repeated trope; it is something that rightly weighs heavy when the loss of a life is at the centre of the inquiry, and particularly so when agents of state are implicated in the tragic death of a black man in custody.  It is, therefore, unsurprising that in the recent case of Dyer heavy justification was required for preventing the deceased’s parents, partner and son from watching the faces of the police witnesses whilst they gave their inquest evidence.

Although balancing potential risks to police officers from those who may wish them harm could justify their giving evidence behind screens and so not open to public scrutiny, it was a step too far, held Mrs Justice Jefford, to also prevent the close family of the deceased from seeing the relevant officers’ faces.

The Notification of Deaths Regulations 2019 [1] (here) come into effect on 1 October 2019 and will place a legal duty on ALL doctors who come to know of a death to ensure it has been reported to a Coroner where any of the circumstances that might trigger the Coroner’s investigatory duties appear to be present.  

Although for over half a century, under the Births and Deaths Registration Act 1953[2] the deceased’s ‘attending medical practitioner’ (‘AMP’) has been required to provide the Registrar with a medical certificate of the cause of death (‘MCCD’), until now there has been no statutory obligation upon the AMP, or any other doctor, to either directly notify the Coroner or ensure the Coroner has been informed by another medical colleague of a death falling within the Coroner’s jurisdiction.[3]

The circumstances in which the doctor's notification duty will now arise largely parallel those situations falling under s.1(2) Coroners and Justice Act 2009 which would give rise to the Coroner’s own investigatory duty – i.e. when the doctor suspects the death was violent or unnatural (including from neglect or self-neglect) or that it occurred whilst the deceased was in state detention or where the cause of death is unknown or the identity of the deceased is not established.

"Better safeguards with the additional scrutiny of deaths"

Previously it would often be the Registrar or a Police Officer who would notify the Coroner of a death in the community. From tomorrow, wherever a  a notifiable death has occurred of which a doctor is  aware that death must also be reported directly to the Coroner by a medical practitioner.

Fullick v The Commissioner of Police of the Metropolis [2019] EWHC 1941 (QB), 25 July 2019 (judgment here)

The funding of representation for the bereaved at inquests is not just an un-level playing field, but a total quagmire often more akin to the aftermath of an outing of the 1988 Pontypool front row on a rainy day in December. The costs of representation at an inquest will only be met from public funds in cases deemed to be ‘exceptional’ (where, as a minimum, Art 2 is engaged or where it can be shown that the provision of advocacy for the bereaved family at the inquest is likely to produce significant benefits for a wider class of people). Calls for non-means tested funding for the bereaved, even though supported by the Chief Coroner,[1] have been rejected.[2] [3] Even the families of those killed in the London Bridge attack were told it was not in the public interest for them to receive state funding at the inquests.[4]

Against that background, it is unsurprising that there is a growing body of case law regarding the recovery of the bereaved’s inquest costs as part of the costs of a subsequent successful civil claim. The amounts at stake can be very large even though the civil claim will often settle pre-action following pejorative inquest findings.

Some of the principles in play are now helpfully set out in the recent case of Fullick – an appeal of a Deputy Master’s order that the Met Police should pay costs of over £88,000 following the pre-action settlement of a claim for damages for breach of Art 2, negligence and misfeasance in public office in a death involving the police.

The decision is worth a read for its consideration of the purpose and function of an inquest, as well as its setting out of the principles underpinning the recoverability of inquest costs.

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” 

R (Chidlow) v Senior Coroner for Blackpool and Flyde [2019] EWHC 581 (Admin) 12 March 2019 (judgment here)

Humans’ bodies being such complex organisms it is unsurprising that medical causation is often extremely complicated and that the law regarding the legal causation of medical injuries can be particularly convoluted.

Indivisible injuries, multifactorial causation, material contribution, loss of a chance etc. create a precarious legal minefield for clinical negligence lawyers to navigate before one even begins to wander into the less well marked territory of the coronial jurisdiction.

Here one must step even more carefully around the danger zone of semantics - wondering whether there really is any effective difference between the ‘causation threshold’ words of minimal or trivial or negligible, whilst remembering the ‘causation standard’ of probable is not what is possible, but not forgetting that a missed opportunity to make a difference may still matter and that Art 2 might anyway require the possible to be recorded regardless of proof.

But this week brings good news for all who must negotiate these coronial causation booby-traps. Mr Justice Pepperall has deployed the mine rollers ahead of you – so take off your personal protective equipment and put down the metal detector – if you want to protect yourself from triggering a legal casualty just take some time out to read and learn from the Divisional Court’s erudite exposition of two fundamental points regarding causation at inquests: 

  • Causation is more than a matter of medical statistics - even where survivors are a majority category.

Something more than being a potential figure in a statistic will be needed that suggests the deceased would probably have been in the category of survivors;[1]

  • There is an important difference between being able to identify what someone died from and being able to say whether, regardless of what precisely caused their death, their life could have been saved with earlier medical attention.

Unfortunately a failure to discern that essential difference led the Senior Coroner in the present case to err in law when he withdrew from the jury the question of whether an admitted delay in an ambulance attending a man contributed to his death.   The Coroner had wrongly concluded that, because there was no clear cause of death, it was not safe to allow the jury to consider the causal effect of the delay in him receiving treatment.

"Establishing a medical cause of death was not essential to being able to form an opinion as to the effect of delayed treatment."

Moreover, the medical expert’s evidence on survivability was not an opinion based solely on statistics. The expert’s view that the deceased would have lived with prompt treatment also relied upon clinical experience; accounts of the deceased’s condition when attended; reading of the other medical evidence (specifically the post-mortem findings and the lack of any underlying disease or infection in an apparently fit young man).   The jury were not bound to accept this expert’s opinion, but his view was not so obviously unreliable that it was not safe to leave the issue of causation to the jury.

What does the Government’s 'Final Report: Review of Legal Aid for Inquests' mean for Advocates?

This report was published in February 2019 (see the report here). The section entitled ‘Making sure inquests remain inquisitorial’ at paragraphs 184 – 202 is particularly worth reading.

The estimated cost of providing representation for families at inquests where the state is represented (a recommendation under review) is a further £30-£70 million.   The Government has decided not to provide that money. Therefore, the inequality of arms between families and state actors continues. (This is an issue on which many at Inquest Blog Towers have views - see here for our earlier post).

No biggie though because, with an alchemical ability that relegates Dr. John Dee’s wizardry[1] to key stage 1, the Government has eliminated misconceived family negativity and accentuated how inequality is not only positive for everyone but also good for the system! 

Re: Finucane’s Application for Judicial Review [2019] UKSC 7; [2019] 2 WLUK 382, judgment, 27 Feb 2019, here

In February 1989 Patrick Finucane, an Irish Catholic lawyer, was eating dinner with his wife and children when gunmen forced their way into his home and shot him 14 times. Thirty years later this murder remains one of the most notorious events of the Northern Ireland ‘Troubles’.

An inquest the following year examined only the immediate circumstances of the death.  Before long, however, it emerged that there was, as his widow suspected, collusion between the murderers and members of the security forces.  The British Government have acknowledged and formally apologised for that collusion. Despite a subsequent guilty plea to the murder by one loyalist paramilitary, none of the numerous investigations into the killing have identified the members of the security forces involved or the assistance provided. There has still been neither an Art 2 inquest nor any formal public inquiry into the state involvement.

The Supreme Court have now determined that, whilst the decision not to hold a public inquiry was lawful, in the circumstances of Mr Finucane’s death Art 2 does require that there is a further investigation conducted which has the means to identify the perpetrators. Whilst the precise form of that investigation will not be prescribed by the courts and remains a matter for the government, whatever form of investigation or inquiry is adopted must meet the Art 2 procedural obligations.

From the jaws of the Care Quality Commission this month comes the first ever fine issued for breach of the Duty of Candour.[1]  Bradford Teaching Hospitals NHS Foundation Trust have been given a fixed penalty notice for £1,250 for failing to apologise to a bereaved family within a ‘reasonable’ time.

A baby had been admitted to Bradford Royal Infirmary in July 2016. Delays in diagnosis and missed opportunities to admit him had been recorded as a notifiable safety incident, yet the family were not informed of this and did not receive any apology until October (writes the CQC).  

The CQC’s action does not relate to the actual care provided to the child, but rather to the fact that the NHS Trust was slow to inform the family that there had been delays and missed opportunities in his treatment.

Apparently the hospital identified and reported their breach to the CQC themselves, and have implemented an awareness-raising programme across their staff to avoid this happening again. Whilst in theory the CQC have powers of prosecution, in the circumstances, this relatively small fine seems more proportionate. 

In the matter of Steponaviciene’s Application [2018] NIQB 16.11.18 judgment here

As coroners, lawyers and the bereaved wait to find out how the Court of Appeal will decide the Maughan case this coming April, [1] a decision from across the Irish Sea has looked in detail at the English and Welsh Divisional Court’s decision in Maughan and found no flaws in its “careful and persuasive” reasoning. For the time being at least, the issue of whether the deceased died from suicide should be decided on the balance of probablities in Northern Ireland just as in the English and Welsh Coroners' courts.

In a detailed judgment McCloskey J has also laid some of the groundwork for anyone resisting the English appeal.[2] In considering the arguments in Steponaviciene’s Application the judge reviewed nine cases put before him that the court had not been referred to in Maughan at first instance.   Roundly dismissing the suggestion that any of these cases rendered the Maughan decision per incuriam, the judge lamented that one of the “unfortunate repercussions of the internet explosion was the routine inundation of electronically available judicial decisions belonging to multiple levels in the hierarchy of the legal system without proper regard to the doctrine of precedent.”    

Re: The inquest into the death of Helen Bailey [2018] EWHC 3443 (Admin) 12 December 2018 Judgment here

It is “elementary that the emergence of fresh evidence which may reasonably lead to the conclusion that the substantial truth about how an individual met his death was not revealed at the first inquest, will normally make it both desirable and necessary in the interests of justice for a fresh inquest to be ordered”. So stated the Lord Chief Justice when ordering the fresh Hillsborough Inquests.[1]

It might then be thought that a Senior Coroner overturning their own (or their predecessor’s) inquest on the grounds of significant fresh evidence pointing to the death being a homicide would be a simple process: after all the Coroner is hardly likely to have misjudged the importance of that new evidence recently revealed. Yet the cumbersome requirements under s.13 Coroners Act 1988 mean that a Senior Coroner who believes that justice requires a fresh inquest must still follow the time consuming two stage process of, first, applying to the Attorney General’s Office for permission to make an application[2] and once that permission is inevitably granted, follow a second and separate process of making an application to the High Court.

R (Paul Worthington) v Senior Coroner for Cumbria [2018] EWHC 3386 (Admin), 11 December 2018. Judgment here

Many will recall the much publicised judicial review brought by the Adath Yisroel Burial Society, [1] which led to the Senior Coroner for Inner North London’s “cab rank” burial policy being quashed. When it came to costs, the Court held that the Coroner had “crossed the line” from merely seeking to assist the Court on aspects of law and procedure into arguing the correctness of the decision under challenge. At that point she was no longer protected by the general rule that coroners who remain neutral in judicial review challenges to their decisions should not be held liable for the applicant’s costs.[2] Partial costs were awarded against her.   

Even ‘neutrality’ in the face of an inevitably successful application will not necessarily mean costs will be avoided if the Coroner behaves unreasonably. In Hopkins  the Swansea Coroner unreasonably refused to sign a consent form when the bereaved family’s s.13 application was clearly bound to be successful. The Coroner was ordered to pay all the applicant’s costs from service of the claim.[3]

In another much discussed case this year of Maughan [4] (concerning the lawfulness of the Coroner’s directions on the standard of proof for suicide) the Coroner advanced reasons why the guidance on which his directions had been based was “arguably correct”, yet was said to have maintained a “neutral stance” – perhaps hoping to avoid the potential adverse cost consequences of losing the claim (although the outcome was a score draw and the judgment does not suggest that any application for costs was made either way).

The defendant Coroner in the recent Poppi Worthington case, [5]  through his counsel, sought to maintain that he too was taking a “neutral stance”. The three judge Divisional Court (which included the Chief Coroner) disagreed, observing that the Coroner had, in practice, sought to persuade the Court that the claim should be refused.  

“Both parties clearly sought to persuade us, to the best of their considerable ability, that their submissions should be preferred.”

The Court noted that, despite the Coroner’s asserted ‘neutrality’, had the claim been successful, the Claimant would have been entitled to his costs against the Coroner.

R (Worthington) v Senior Coroner for Cumbria [2018] EWHC 3386 (Admin) 11 December 2018 Judgment here

When public funding for deserving families at inquests is so hard to come by it is mystifying how the Legal Aid Agency can make a decision to spend their limited funds on an apparently unmeritorious challenge to inquest conclusions by one who was involved, in the most appalling way, in the circumstances leading to the death of the deceased. 

In the Worthington case, the acknowledged motivation of the abusive father in bringing his challenge was to try to hide his actions in the lead up to his daughter’s death from those who might look at her Record of Inquest (ROI) in the future, yet his claim was brought with the benefit of public funding.

Poppi's death

The account of how Poppi Worthington met her death is an extremely sad and disturbing story.   Poppi was 13 months old when she died at her home.  When Mr (now Lord) Justice Peter Jackson considered this case in the family court proceedings in 2014 and 2016 [1] he concluded that in the hours before Poppi’s death, the Claimant, her father, had perpetrated a penetrative anal assault on her, either using his penis or some other unidentified object.  Poppi died shortly afterwards from a cause which the Judge was unable to ascertain.  

The fresh inquest held in 2017 [2], revisited the issue of whether Paul Worthington had sexually assaulted Poppi prior to her death and, if so, whether that had caused or contributed to her death.  In a detailed document of over 100 pages the Coroner set out his reasoned factual findings on the extensive expert and factual evidence.  He concluded that Paul Worthington had anally penetrated Poppi in his bedroom and then left Poppi to sleep beside him in such a position that her breathing was compromised, either due to the position of the bedclothes, her position within the bed, or overlaying, or a combination of all three.   The anal penetration had not caused her death. Rather, the Coroner concluded that Poppi had died from asphyxia resulting from obstruction of her airways whilst she was asleep in her father’s bed.

The Judicial Review claim

Paul Worthington specifically accepted that the Coroner was required to make a finding of fact as to whether a penetrative assault had occurred. He did not challenge that finding.  Indeed he could hardly have done so given that a High Court judge had twice previously come to a similar conclusion about his despicable abuse of his baby daughter. 

Mr Worthington’s complaint was that the Coroner had recorded in box 3 of the Record of Inquest [3] that:

“…at some time after 2.30am, [Poppi] was taken from her cot to a double bed where she was anally penetrated. She subsequently went to sleep in the double bed with an adult sleeping close to her. .. her ability to breathe was compromised by her unsafe sleeping environment…”

Mr Worthington judicially reviewed the Coroner's conclusion.  His case was that the words above in italics trespassed into the wider circumstances of the death in a way that was not permitted in a non-Article 2 inquest.  As the anal penetration had not caused Poppi’s death, he argued it could not be relevant to “how” she died, and so should not have appeared on the Record of  Inquest.

The Senior Coroner for Inner West London, Dr Fiona Wilcox, has made a report to prevent future deaths[1] (a “PFD report”) in connection with her investigation into deaths following the Grenfell Tower fire. Her report (here), issued on 19 September 2018, is a good illustration of the potential breadth of a coroner’s powers: the report focuses not on fire safety but on future health screening and support for those survivors and others who now face the physical and psychological consequences of their involvement in this tragedy. 

The Senior Coroner’s concern is that some survivors and responders at the scene may have been exposed to significant inhalation of smoke and dust containing toxic substances, and so are left at risk of developing health conditions. Furthermore, many of those affected by the incident have suffered emotional trauma and harm to their mental health and need appropriate mental health support. Her report, directed at NHS England, is aimed at minimising the risk of affected persons slipping through the net and being lost from appropriate supportive services.

However, as the earlier coronial report in 2013, following the worryingly similar events in the Lakanal House Fire chillingly reminds us (see earlier commentary here), these coronial reports have little teeth.  

There is no coronial power in relation to the content, adequacy or implementation of the response to a PFD

Despite the breadth of the power to make a PFD report, they are only reports, there is no mechanism for implementing or enforcing the recommendations implicit in such PFD reports, and no systemic approach to maximise their effectiveness nationwide.

In the matter of Hugh Jordan [2018] NICA 34 (15 October 2018) decision here

As the ongoing Maughan[1] litigation focuses minds on the standard of proof applicable for a suicide finding at an inquest, it is perhaps surprising how little thought is given to the issue of the burden of proof at an inquest. However, in the latest episode in the long running saga of the inquest into the death of Pearse Jordan, the Northern Ireland Court of Appeal has added some clarity to the position by recognising that there can, in some situations, be a burden of proof even in an inquisitorial setting. Nevertheless, determining factual issues in inquests will, sometimes, not be possible.

Burden? Standard?

First, a quick reminder of your second day of evidence lectures at law school:

  • Standard of proof: the level of evidential certainty required to establish a fact.
  • Burden of proof: the obligation on a party to adduce evidence to establish a fact. 

Of course I hear you say, even a law school fresher would know there is no burden of proof within inquisitorial proceedings! Surely the clue is in the name? An ‘inquiry’ asks questions and establishes facts, but it does not require anyone to prove or disprove anything. An inquiry has no parties; no one has a formal case to put or a case to meet.

But just as the Maughan case (Blog here) has reminded us all that assumptions are often the errors we don't realise we are making, the NI Court of Appeal now tells us we would be wrong: when Art 2 is engaged there can be a burden of proof in an inquest –  one to be discharged by the state.

Coroner for the Birmingham Inquests (1974) v. Hambleton & Ors. [2018] EWCA Civ 2081 (judgment here)

On the evening of 21 November 1974 two successive explosions tore through two busy city centre pubs in the heart of Birmingham.  The bombings, thought to be perpetrated by the IRA, resulted in the largest UK mainland peacetime loss of life to terrorism in its time: 21 innocent people were killed and 220 more were injured.

The inquests were opened but adjourned pending a criminal investigation.  The following year, six men were convicted and sentenced to life imprisonment. The miscarriage of justice involving the West Midlands Police that led to the release of ‘the Birmingham Six’ by the Court of Appeal in 1991 is now notorious.  Despite the subsequent police investigations no further convictions have followed and the perpetrators of these atrocities remain unidentified and unpunished.

Who then was responsible for the deaths of the 21 victims? How did they come to die in these circumstances? Could their deaths have been prevented?  The answers as to what happened for over 44 years ago remain hidden in a metaphorical ‘chamber of secrets’.

The key question is what is the scope of the inquest? Although inquests must not become proxy criminal trials, is the identity of those involved in violent deaths properly within the scope of an inquest?

Whilst some of the obstacles beyond the trapdoor will be navigated in the forthcoming inquests, following the recent decision of the Court of Appeal it now seems that the door that might lead to the final secret, the naming of the evil-doers, is not to be unlocked.

R (Allman) v HM Senior Coroner for Liverpool and Wirral.  CO/3230/2018 decision here 25.9.18

The short and desperately tragic life of Alfie Evans, and his parents’ heart-rending fight to have him transferred to Rome for continuation of his life sustaining treatment, has recently been fully played out in the public arena.   

The public hearings in the High Court[1] and the four appearances in the Court of Appeal[2] were not only all open to the public but the details were widely reported throughout the print and digital media.  On two occasions the family sought permission to take the case to the Supreme Court[3] and the European Court of Justice[4] but on each occasion those applications were dismisssed.  Those hearings were on paper without any oral submissions but once again the determinations were made public.

The relevant clinical information and extracts of the various expert opinions relied upon by the Courts at each stage are set out in the judgments.  They each confirm the unanimous agreement between all of the medical experts involved – including specifically all of the experts instructed by the family – as to the catastrophic and untreatable, progressive, neurodegenerative condition from which Alfie suffered; there can be no question that Alfie’s death on 28 April 2018 was the result of a naturally occurring condition. 

Against that background it is difficult to understand what more about the facts of Alfie’s death might be learned by those who have since called for an inquest to be held. Unsurprisingly, a judicial review claim challenging the decision of the Liverpool Senior Coroner that an inquest was not required in law has now been considered “totally without merit” in the High Court.

(1) Diane Hopkins & (2) Frances Ryan v HM Coroner for Swansea and Neath Port Talbot [2018] EWHC 1604 (Admin) Judgment here.

This was a straightforward application of the High Court’s power under s13 Coroners Act 1988 to quash the determinations and findings made at an inquest and order a new one, in the light of new evidence.  But the facts make surprising reading and reveal important lessons for coroners.

Mrs Pokoyski was an 85 yr old care-home resident. After a series of strokes left her paralysed she required a puréed diet. Her family were concerned that she was often being inappropriately fed in a reclining position so causing her to choke. One day she was said by care staff to have suffered a ‘bad episode” of vomiting and aspirated vomit; she became ill, struggling to breathe; she was taken to hospital but died a few days later.

Following a post-mortem examination a consultant histopathologist, Dr Thomas, gave the cause of death as “aspiration pneumonia with locally advanced carcinoma of the lung”. However, at the inquest Dr Thomas changed his opinion. Having heard the factual witness evidence he said he now wasn't clear if choking had occurred and that the food material he saw in the lungs might have come from the stomach rather than from aspiration. Dr Thomas now gave a different cause of death - pneumonia caused by lung cancer - which the assistant coroner accepted as part of his conclusion.

However, the deceased’s daughters had legitimate concerns about how their mother had been fed and and so after the inquest obtained an independent expert pathologist’s opinion. Professor Soilleux gave a damning analysis of Dr Thomas’s evidence. Not only had the original cause of death been correct, but the deceased had died from the worst aspiration pneumonia this expert had ever seen under the microscope.

R (Maughan) v HM Senior Coroner Oxfordshire and others [2018] EWHC 1955 (Admin) 26 July 2018 judgment here.

In a roller-coaster judgment the High Court has revolutionised the approach to the conclusion of suicide in the coroner’s courts and has determined that whether the deceased died as a result of suicide is to be determined on the civil standard of proof - on the balance of probabilities.

Judgments such as this are an extremely important reminder to all lawyers of the dangers of making the assumption “it must be right because that’s how it has always been”. Applying the doctrine of stare decisis means the Court would doubtless now say to us all that "whatever you have all been assuming was always the case, you were actually always wrong".

The Claimant submitted that decades (if not centuries) of case law had established that a verdict of suicide at an inquest could only be returned on the criminal standard of proof; Leggatt LJ and Nicol J, however, found that the authorities simply did not bear this out.

The findings of fact and conclusions can be viewed and downloaded here.

HH Peter Rook QC has today handed down his findings of fact and conclusions in respect of the inquest into the death of Private Sean Benton, a trainee soldier, at Deepcut Army Barracks on 9 June 1995.   

He has concluded that Sean died as a result of suicide when he shot himself with a SA80 rifle causing five wounds to the chest. He has found that no third party fired any shots during the incident that led to Sean’s death.

The initial inquest into Sean’s death held a month after his death lasted less than a day and also came to a verdict of suicide. However that inquest was overturned by the High Court in October 2016 when a fresh inquest was ordered.  

The second inquest, commenced in February 2018 and was held to, in part, satisfy the state’s obligations under Art 2 ECHR to proactively investigate certain deaths.

Having heard evidence from 172 witnesses over 40 days of court sittings HH Peter Rook QC has provided narrative describing the circumstances in which Sean came by his death.

Having considered psychiatric expert evidence the judge has concluded that Sean Benton had an undiagnosed evolving Emotionally Unstable Personality Disorder which meant that he would have had great difficulty coping with significant disappointments and stressful life events. On 8 June 1995 Sean had learnt that an application was being made for his discharge from the army, and, profoundly affected by this decision, Sean decided to take his own life.

R (Adath Yisrosl Burial Society and anor) v HM Senior Coroner Inner North London (Costs) EWHC 1286 (Admin) (25 June 2018) Judgment here 

In the closing chapter of a case that has attracted wide media comment, the Divisional Court has now considered whether costs should be awarded against the North London Coroner, whose ‘cab rank’ policy for addressing the administration of deaths in her area, challenged by religious groups who considered that it amounted to indirect discrimination, was quashed in April.

In the substantive case, discussed here, the court held the Senior Coroner’s policy to be irrational and unlawful. She had wrongly fettered her discretion to expedite deaths where there was a particular need or religious imperative to do so.

The remaining question, therefore, concerned costs. In particular, whether the court should follow the general rule in CPR 44.2(2)(a) that in civil actions, including applications for judicial review, the unsuccessful party be ordered to pay the costs of the successful party, notwithstanding that the Defendant was a judicial officer.

As the Court of Appeal has previously made clear in Davies[1], although the award of costs is discretionary, the fact that a coroner loses a case as a Defendant is an insufficient basis, in and of itself, on which to make an adverse costs order against him or her.

The fact that a coroner loses a case is an insufficient basis, in and of itself, on which to make an adverse costs order against him or her.

R (Parkinson) v HM Senior Coroner Kent, Dartford and Gravesham NHS Trust and Dr Hijazi (Interested Parties) [2018] EWHC 1501 (Admin) Judgment here (15 June 2018)

In a tour de force judgment, that deserves plaudits for its several pages of lucid exposition of the application of Art 2 in respect of deaths associated with medical treatment, the Divisional Court have re-affirmed that the Art 2 investigative obligation will not be engaged if what is being alleged amounts to no more than medical negligence by healthcare staff.

Although Art 2 rights could be infringed if an individual’s life is knowingly put in danger by the denial of access to life-saving emergency treatment, the state’s Art 2 obligations do not extend to circumstances where a patient is considered to have received deficient, incorrect or delayed treatment.

That conclusion is perhaps of little surprise given the very recent and authoritative statement of the relevant principles set out by the Grand Chamber of the European Court in Fernandes v Portugal [1] (see our earlier blog).  Indeed once Fernandes was decided in December 2017 the main part of the Claimant’s judicial review claim was already thoroughly holed below the water line.  Mr Parkinson nevertheless sought to urge upon the Court that, if necessary, it should decline to follow decisions of the ECtHR.

Launching the final torpedo, the Divisional Court made it clear that only in exceptional circumstances would the courts in this country decline to follow the jurisprudence of the European Court of Human Rights. Fernandes was to be followed: and, on the facts, there had been no arguable breach of Art 2.

R (Lyttle) v (1) Attorney General (2) HM Senior Coroner for Preston [2018] EWHC, 25 May 2018 Permission decision here

In a useful reminder of the constitutional position of the Attorney General, this Administrative Court decision has made it clear that should the Attorney General refuse to give a fiat this will be the end of the road for any Claimant hoping to make an application under s.13 of the Coroners Act 1988 for a fresh inquest.

Unlike Judicial Review proceedings, where permission to proceed with a claim is sought from the High Court, applicants hoping for an order for a fresh inquest under s.13 Coroners Act 1988 must first seek permission to proceed (a fiat) from the Attorney General. As with the High Court Judicial Review permission stage, the purpose of the fiat is to weed out unmeritorious or frivolous claims.   But unlike the High Court – where refusal of permission on the papers may be followed by an oral permission hearing -   the Attorney General’s decision, which is always made on the papers, will be final.

The Attorney General is answerable to Parliament, not to the Administrative Court in this respect, hence challenging the fiat decision in the High Court is not only futile but, as in the present case, the applicant also risks having costs awarded against them when the Attorney General inevitably succeeds.

R (Maguire) v Assistant Coroner West Yorkshire  [2018] EWCA Civ 6 (17 January 2018)  Judgment here. 

In a sequel to our earlier blog piece the Court of Appeal have delivered their judgment upholding the decision of Mr Justice Holroyde[1] who had found that the Assistant Coroner had been correct to decline to hear oral evidence from nine children who had contact with the killer of their teacher on the morning of her death, and who had heard his threats to kill and/or knew he was carrying a knife,  but had not revealed this to any adult before the death.

The Lord Chief Justice noted that under the Coroners Act 1988 and its predecessors, a coroner was required to examine such witnesses as appeared “expedient” [2] and whilst the formulation is different in the 2009 Act[3] which simply empowers a coroner by notice to require a person to attend to give evidence or to produce evidence, nevertheless, the change has not affected the basis upon which a coroner’s decision to decline to call or seek evidence may be challenged, which is on the usual Judicial Review grounds.[4]  

In dismissing the appeal on all grounds the Court of Appeal endorsed the Coroner’s approach of balancing the value of the evidence against the potential harm to the pupils of giving evidence.   In this case, given the absence of any relevant policies or rules regarding reporting the presence of knives in school, it was very difficult to see how the proposed questioning of the nine pupils would have any value at all. Exploration of the individual child’s thinking in connection with the decisions he or she made that morning when confronted with knowledge of what the killer was saying and doing was not within the scope of the inquest. The decision not to call these witnesses was therefore plainly rational. 

R (Adath Yisrosl Burial Society and anor) v HM Senior Coroner Inner North London and The Chief Coroner of England and Wales (Interested Person) EWHC 969 (Admin) (27 April 2018)   Judgment here.

This is an unhappy case all round. The silver lining is that the Divisional Court went out of its way to facilitate some public education about that most fundamental and cherished of rights, the principle of equality.  Anyone wanting a crash course in: absolute and qualified rights, justification, indirect discrimination and proportionality and the PSED (the public sector equality duty) should head straight to paragraphs 93 to 143 and make an entry on their CPD form.  But the take away point is this: 

People are different. Treating them equally does not mean treating them the same.

The specific issue was whether the Coroner could and should fast track the administration of deaths of Jewish people or whether religion should be left out of account altogether, so that each death, and family, should await their turn in the coronial queue.

The Divisional Court decided that specific point (in appropriate cases they can and should) and then explained what equality means. We suffer discrimination not only when we are treated differently to someone in an analogous situation but also when, being different, we are not treated differently. We are not all the same, one size does not fit all and if we are to be treated equally, a balance must always be struck.

The Annual Coroners Statistics for 2017 that have been published this month, may not be top of the reading list for many inquest practitioners, however they are always worth a summary glance, as the figures reflect the huge volume of work that Coroners deal with behind the scenes that is often not appreciated when there are more headline grabbing inquests or judicial review cases to be reported.

The key trends (which it is well worth knowing about) are summarised here, along with important, new information about research demonstrating the reliability of non-invasive post mortem examinations by enhanced CT scanning (PMCT) and why greater use of that modality is strongly to be encouraged. 

Summary of the Annual Report 

There were 229,700 deaths reported to Coroners last year. However, the annual number crunching reveals only two notable year on year changes once the impact of DOLS deaths is taken into account: first, a welcome reduction in deaths of those detained under the Mental Health Act and second, a massive increase in the number of non-invasive post mortem examinations conducted.

Key figures

  • 11% fewer deaths reported

  • 18% fewer inquests opened

  • 22% reduction in mental health deaths

  • 120% increase in non-invasive post-mortem examinations.

Lopes de Sousa Fernandes v Portugal (Application no. 56080/13) (ECtHR Grand Chamber, 19 December 2017) judgment here.

The ECHR Chamber judgment in Lopes (15 December 2015) had the potential to expand the situations where a Middleton style “Article 2 inquest” would be required. The Chamber judgment appeared to widen the scope of Article 2 protections to incorporate errors of judgment on the part of health professionals and miscommunication between hospital departments. If poor judgment calls and miscommunications were now to be considered a substantive breach of Article 2 then many hospital deaths would require an inquest fully compliant with Middleton principles. It was perhaps only the unavailability of the judgment in English that held back the flood. [1]

If poor judgment calls and miscommunications were now to be considered a substantive breach of Article 2 then many hospital deaths would require an inquest fully compliant with Middleton principles.

However, the Grand Chamber of the European Court of Human Rights (“the Court”) has now reversed the previous Chamber judgment and held, by a 15:2 majority, that there was no violation of the substantive limb of Article 2 in respect of ‘merely’ negligent hospital treatment.

The judgment provides important clarification on substantive Article 2 claims and would appear to limit such claims in the healthcare sphere to cases of a denial of life-saving treatment caused by systemic/structural issues rather than individual error. The Court has now made clear that “mere error or medical negligence” is not sufficient.[2]

The case however remains of relevance for inquest practitioners as the Court upheld the finding that there had been a violation of the procedural limb of Article 2 owing to the delay in implementing the extant state structures to investigate the death.

R (Silvera) v Senior Coroner Oxfordshire [2017] EWHC 2499 Admin. 20.10.17  (decision here)

Inquests play an essential role in ensuring public accountability when our hard pressed public services don't always manage to get things right.   That inquests allow for the full involvement of the family when publicly exploring the facts and coming to the understanding of what has happened is one of their most important features. The independence of the Coroner (or jury) when reviewing the circumstances of a death is crucial; as is the Coroner’s power to then notify any concerns to those who can take steps to make things safer for us all in the future.

Against that background it should, perhaps, not even need the added impetus of Art 2 ECHR to understand why some deaths are crying out for a publicly held independent investigation. Whilst the coronial jurisprudence around Art 2 ECHR and the investigative obligations that flow from it can be complex, it is hard for the outside observer to discern why the Senior Coroner in this present case was not even persuaded that Art 2 ECHR was engaged, let alone that an inquest was then required to satisfy the State’s investigatory obligations.  

The facts

The bare facts are that a woman, who all accepted was mentally unwell, had absconded from a psychiatric hospital by jumping out of a window just one day after the decision had been made to change her status to that of an informal patient (and so not continue with her detention under the Mental Health Act 1983).   The woman had also absconded the previous month, and at that time the staff had told police the woman was “very unwell” and “at risk of causing violence”. On this second occasion the police were again asked for assistance to return her to hospital and were told that the staff believed the patient “might do something” and “may be holding [her mother] hostage”. Yet she was nevertheless left in the community un-assessed for a further five days. At some point during that period she killed her mother.    

Engaging Art 2

Even a cursory reading of Rabone and Sargantson[1] would suggest it was at very least arguable that the state’s Art 2 obligations were engaged here, given the involvement of these two public bodies - and particularly as an internal NHS inquiry had already pointed to a number of shortcomings in the patient’s care and risk assessment.   Indeed the Chief Coroner, who gave the decision of the High Court, seems to have felt it was so abundantly clear that Art 2 was engaged that he didn't even bother wasting any space in his judgment explaining why[2]

The Senior Coroner, however, did not accept that Art 2 was engaged and further, even if it was, did not agree that resuming the inquest was required in the context of a guilty plea and the public bodies’ having already conducted their own investigations.

As the Chief Coroner has now made abundantly plain: where there has not already been an independent investigation of a death that has allowed for the proper involvement of the family and with a sufficient element of public scrutiny, then the inquest must be the vehicle to achieve this.

R (Dr Siddiqi and Dr Paeprer-Rohricht) v Asst. Coroner for East London.  Admin Court  CO/2892/2017 decision 28 Sept. 2017 (decision here)

Making a report that may prevent future deaths (a ‘PFD report’) under reg. 28 of the Coroners (Investigation) Regulations 2013 is an important but often misunderstood coronial power.

The issuing and receipt of a PFD report entails no more than the Coroner bringing some information regarding a public safety concern to the attention of the recipient. A PFD report is not punitive in nature, despite some interested persons construing it as such. It engages no civil or criminal right or obligation on the part of the recipient other than the obligation to respond to the report in writing within 56 days. The nature and content of that response is wholly a matter for the recipient.  In their response the recipient can choose to agree or disagree with matters within the report or rebut any determination of the facts that is expressed by the Coroner. The recipient can object to or accept the invitation within the PFD report to take action, and could even choose to respond by expressing the view that no action is required to allay the Coroner’s unwarranted concerns.

The appropriate remedy for those wishing to take issue with the content of a PFD report is to respond to the report.

 Against that background it is unsurprising that a recent attempt to Judicially Review a Coroner’s decision to issue a PFD report has fallen at the first hurdle

Re HM Senior Coroner for North West Wales (2017) EWHC (Admin) 4 October 2017 (no transcript yet available) 

When unidentified human remains were found on a Welsh beach in 1994 the cause of death was unascertained: the inquest returned an open verdict with the deceased unknown. However, tissue samples had been retained and advances in forensic science had recently allowed a DNA profile match to the brother of a woman who had disappeared in 1994. The circumstantial evidence strongly indicated that the deceased was his missing sister.

It must have been beyond question that these new facts and evidence made a further inquest that would now properly identify the deceased both necessary and desirable in the interests of justice.   The problem facing the Senior Coroner was that because an inquest had already been held the coroner was “functus officio” and had no power to quash the original inquest.

The cumbersome mechanism under s.13 Coroners Act 1988 for quashing a previous inquest now had to be followed to allow a fresh investigation to commence under s.1 CJA 2009. This involved the Coroner first making an application to the Attorney General, waiting for his authority to be given (under a fiat) before an application to the High Court under s.13(1)(b) could be made.

 Is it seriously considered that a Senior Coroner’s own application will ever be unmeritorious? 

It is no surprise that the A-G, followed by Lord Justice Treacy and Mr Justice Dingemans all readily agreed to a fresh inquest being held. Perhaps the only surprise is that it required a Divisional Court of two judges to consider the matter.

 This case is yet another example of time and money being unnecessarily spent before the obviously correct thing can be done. A s.13 application to the High Court can only be made “by or under the authority of the Attorney-General”. It is not unknown for obtaining that permission to take over 4 months in the most simple and clear of cases.

Permission stages in court applications, such as the fiat required here, are of course a good mechanism for weeding out frivolous, ill-founded or unmeritorious applications at an early stage. But is it seriously considered that a Senior Coroner’s own application will ever be unmeritorious?  The delay inherent in the fiat process merely extends the waiting for families and increases administrative costs for coroners.  The time must have come for revision of the legislation so that a Senior Coroner no longer needs the Attorney General’s permission to make a s.13 application.

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

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

R (Maguire) v Assistant Coroner West Yorkshire [2017] EWHC 2039 (Admin) 14 August 2017 (judgment here)

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.

R (Scarfe & Ors) v Governor HMP Woodhill & SoS Justice [2017] EWHC 1194 (Admin) (23 May 2017)  judgment here

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 PFD1 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.

R (Gudanaviciene) v Immigration and Asylum First Tier Tribunal [2017] EWCA Civ 352, 11 May 2017 - judgment here

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.

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  here) . 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.

R (T) v HM Senior Coroner for the County of West Yorkshire [2017] EWCA Civ 318  judgment here

A young woman arrived at A&E with her mother. They were carrying a shoebox. Inside the shoebox was the body of a baby girl.

The baby’s mother, aged 19, had kept her pregnancy a secret and delivered the child alone, in her bedroom six days earlier. She said she never heard a cry and did not know whether the baby had been born alive. She hid the body in a shoebox under the bed. Three days later her mother had discovered the box. The women then kept the events from other family members and waited out the weekend before taking the body to hospital.

Examinations by a pathologist and specialist neuro-pathologist left the death unexplained: there was no identified natural disease or injury. Nor could they decide whether the baby was alive at birth. The CPS reached the view that there was insufficient evidence to charge anyone with a criminal offence. The woman’s initial allegation that her conception had followed a rape was withdrawn after police investigations revealed a consensual sexual relationship.  

When the Coroner proposed to hold an inquest into her baby’s death the young woman brought a case to the High Court, arguing that the Coroner had no such power and that her identity should be kept anonymous. She lost decisively on both counts.

"the conduct of the Claimant was not in any sense a private matter” 

Shaw v Leigh Day (A firm) [2017] EWHC 825 QB (judgment here)

Attention family representatives! Absolutely nooo pressure at all, it's just that if you don’t get your client the closure they want out of an inquest, now you can be sued for damages for causing them distress. That is the effect of this recent High Court decision.

The tweetie-birds-round-head inducing litigation saga is set out in more detail below. In a nutshell, Mrs Shaw's elderly father had a cardiac arrest following complications of a trans aortic valve procedure (TAVI). She instructed Leigh Day, one suspects on a private basis (although this isn’t clear from the decision), and there was an Article 2 inquest at the end of which the jury concluded that the death was an unintended result of a therapeutic procedure and made no criticisms of anyone.

The inquest left Mrs Shaw dissatisfied and, so far as she was concerned, lacking answers to key questions. Even though there has been since been a successful negligence action against the hospital and the surgeon, the High Court has now cleared the way for her to claim £5,000 for mental distress from Leigh Day caused by what she says is the poor job they made of getting disclosure and representing her at the inquest.

R (Duggan) v Asst Coroner North London and (1) Metropolitan Police Commissioner (2) Serious Organised Crime Agency (3) IPCC (4) DS Belfield (5) DC Faulkner (Interested Parties)  [2017] EWCA Civ 142 (judgment here)

Mark Duggan’s fatal shooting by Metropolitan Police officers gave rise to widespread public disorder across the country. The inquest jury’s finding that the cause of death was “lawful killing” has, unsurprisingly, remained matter of public debate and given rise to several legal challenges.

The Court of Appeal has now held that:

“There is nothing in either domestic legislation or the jurisprudence of the ECHR which requires that, in every case where a self-defence justification is raised at an inquest, a specific direction must be given to the jury that, in deciding whether a belief of imminent threat was honestly and genuinely held, the reasonableness or unreasonableness of that belief from the viewpoint of the person claiming the defence is a relevant consideration.”

R(Ferreira) v HM Senior Coroner South London [2017] EWCA Civ 31 (26 January 2017) (judgment here)

Reading about the 1888 Victorian Railway Commissioners case when studying for the bar I always wondered what it might look like if the ‘floodgates’ so fiercly guarded by judges in those old judgments were actually prised open. Well now I know.

The combination of the Mental Capacity Act ‘Deprivation of Liberty Safeguards’ and the Supreme Court’s 2014 Cheshire West[1] decision have produced a legal tsunami that has deluged the Court of Protection. This has been followed very closely by a smaller but equally damaging tidal wave that inundated Coroners’ Courts once holding an inquest into the death of any person who was the subject of a MCA DOLS authorisation was deemed mandatory.    

If the appellant had won this present case, and a death in a NHS hospital due to the physical illness of someone lacking capacity had amounted to a death when deprived of liberty (so in state detention), and therefore required a jury inquest, then the already swamped Coroners Courts might have finally submerged.  

Happily, however, the watery metaphors can now dry up, as a combination of the Policing and Crime Bill (soon to be given Royal Assent) and the Court of Appeal’s most recent common sense judgment in the Ferreira case have firmly rebuilt the levee around the Coroners’ Courts, handing a few sandbags to the Court of Protection at the same time.

Cevrioğlu v. Turkey, ECtHR (Application no. 69546/12) (4 January 2017) (judgment here)

Coroners feeling relief that amendments to the Policing and Crime Bill will mean that the burden is about to be lifted from them of conducting inquests after any death of a person subject the Mental Capacity Act DOLS provisions might wonder if their workload will nevertheless increase following this recent judgment of the European Court of Human Rights (ECtHR) that clarifies that the ambit of Art 2 covers failures in the state’s regulatory oversight of private companies’ actions. Where there are arguable grounds to suspect such a regulatory failure that would otherwise have ameliorated a risk of death an Art 2 inquest may now be required.

Where there are arguable grounds to suspect a regulatory failure to ameliorate a risk of death an Art 2 inquest may now be required.

The facts of the case are tragic: in 1998 the applicant’s ten-year-old son, and his friend were found drowned after falling into a 2 metre deep water-filled hole on a construction site where they had been playing near their home. The construction site was the responsibility of a private company, however construction permits had been issued by the Municipality of Antakya which could also issue warning and enforcement notices if unsafe practice was revealed.

When the domestic courts failed to provide a remedy for the applicant’s claim against the Municipality, for failing in its responsibilities for inspecting the work, he applied to the ECtHR for redress. The ECtHR held unanimously that there had been a violation of his substantive and procedural rights under Art 2 ECHR and awarded EUR 10,000 in damages.

R (IPCC) v IPCC [2016] EWHC 2993 (Admin) (25 November 2016) (judgment here)

The value of a Coroner’s inquest in opening up matters to public scrutiny is clearly demonstrated by this highly unusual application by the Chief Executive of the IPCC who, following a searching inquest, brought proceedings against his own organisation to overturn its flawed report into police conduct.

Jordan Begley died following contact with police during which a Taser had been used and he had been restrained. Police officers had been called to his house by his mother, who was concerned that Jordan might become violent. He had been drinking and was upset about having been accused by others of stealing a handbag. His mother said that he had a knife and he wanted to go outside to confront his accusers. A number of officers arrived at the scene and a Taser was used. Once tasered, Mr Begley fell to the floor and was restrained face-down. In the course of bringing him under control, one of the police officers delivered two strong punches as “distraction strikes” to Mr Begley’s back to enable him to be handcuffed. It shortly became clear that Mr Begley was very unwell and despite being taken to hospital, tragically, he died shortly thereafter.

The IPCC report into the incident, which was available to the inquest, had found that no officer had any case to answer for misconduct or gross misconduct. The inquest jury did not agree.

The inquest jury reached a narrative conclusion that was far more critical than the IPCC report, finding that:

  • Mr Begley had died from a stress-induced cardiac arrest;
  • the use of a Taser was “not reasonable”;
  • the length of time for which the Taser was deployed (over 8 seconds) was not reasonable;
  • there was no need for a police officer to have punched Mr Begley twice;
  • the police had not been sufficiently concerned with Mr Begley’s welfare once he was handcuffed; and
  • failings by police officers had materially contributed to the death.

In light of the inquest findings the IPCC reviewed its own investigation and found errors in its own guidance and the independent investigation report

In the face of such public criticism of police actions it was clear that the IPCC report needed to be reconsidered, but the only mechanism to do so was for the Chief Executive to bring judicial review proceedings against his own organization, so as to quash a report and enable a fresh investigation to take place. That claim was opposed by the police officers involved.

McDonnell v Assistant Coroner for West London [2016] EWHC 3078 (Admin) 6 December 2016 (judgment here)

Leo McDonnell died due to a fatal cardiac arrhythmia. At the time of his death he was prescribed nine items of medication including citalopram, amitriptyline, quinine and codeine. To prescribe citalopram alongside some of these drugs was contraindicated and his prescribed daily dose of citalopram was higher than the recommended maximum. There was a factual dispute between the treating doctors and the claimant regarding these prescriptions. In summary the doctors stated that they had explained the serious risk to the heart and risk of death to him in straightforward terms. The claimant’s evidence was that the doctors had spoken in medical jargon and failed to convey that there was a serious risk. Her position was that the prescribing doctors should not have shifted responsibility by asking the deceased to consent to the continuing over-prescription.  

There were two main candidates for the cause of Mr McDonnell’s death. The first was the mixture of medication he was taking and the role of the 15 codeine tablets he had taken on the day of his death. The second was a vaso-vagal event. The Assistant Coroner found that the death was from a combination of both potential causes, citing a “fatal cardiac arrhythmia triggered by a vaso-vagal event in the presence of excessive codeine, together with citalopram, amitriptyline and quinine at levels consistent with prescribed medication.” She concluded the death was by “misadventure”.

Mr McDonnell’s widow was not satisfied with these findings or the narrative conclusion and so applied under s.13 Coroners Act 1988 to quash the inquest. She argued that the coroner was not entitled to have found that an overdose of codeine contributed to death, as this was inconsistent with the post mortem evidence, nor to have found that the deceased had given his consent to the citalopram being prescribed alongside the other contraindicated medication.

Her challenge failed:

"That a different coroner might take a different view of the evidence does not mean that it is in the interests of justice to hold a new inquest.”

Secretary of State for the Home Dept v Senior Coroner for Surrey [2016] EWHC 3001 (Admin) 23 November 2016 (judgment here)

Senior Coroners still smarting from being described as holding "a relatively lower judicial office” by Mr Justice Singh in the Norfolk Coroner v AAIB case last month have now been dealt a second blow by Cranston J when he made it very clear that not only are Senior Coroners, as a category, not among those able to see sensitive material related to issues of national security, but that the Secretary of State can rely upon the assertion of a general policy not to provide Coroners with such material and so does not have to provide any evidence that disclosure to the particular Coroner will in itself result in a real risk of serious harm to national security.

When Alexander Perepilichnyy, a Russian national, died suddenly in November 2012, while jogging near his home in Surrey, the circumstances aroused suspicion in some as to whether he had been unlawfully killed by agents of the Russian state due to his alleged role in helping to uncover a major fraud.

During the course of his investigation into Mr Perepilichnyy’s death, the Senior Coroner had issued requests for evidence directed at the Security Service and the Secret Intelligence Service.   

In an “unprecedented” application the Secretary of State applied to the High Court for an order permitting the non-disclosure of documents to the Senior Coroner in the inquest proceedings on the ground that such disclosure would damage the public interest. 

The Secretary of State had refused to allow the Senior Coroner, who did not have developed vetting (‘DV’) security clearance, to view the original material.  Although the Senior Coroner accepted that there was material which he was not able to review because of its sensitivity; he had appointed DV security cleared counsel who the government agreed could view the information and provide an anodyne gist to him.     The confidential gist was prepared at a level of generality to enable the Senior Coroner to consider the material with his counsel. The Secretary of State then made a PII application in respect of the gist, but the Coroner considered that the submissions made on he behalf in relation to the application were inadequate, as they were not supported by evidence.  The Senior Coroner informed the Secretary of State that he required a PII application by way of a Ministerial certificate; a Ministerial certificate was duly provided however rather than being limited to the gist it covered the entirety of the material which meant that the Senior Coroner was unable to see it, consequently he was unable to determine the PII claim.

The Senior Coroner accepted that he could not now determine whether the PII claim was properly made because he needed to see the disputed material in order to conduct the balancing exercise required.    The question for the High Court was whether that Court should exercise its jurisdiction to consider the Secretary of State’s PII application in the circumstances.

Re JS (Disposal of Body)  EWHC 2859 (Fam) 10 November 2016

Last month saw the three Brexit judges on the front pages, unfairly lambasted by the media just for doing their jobs properly. It’s a shame that the press who seem, on the whole, to rather like this latest Family Court decision, haven’t sought to make Mr Justice Peter Jackson their cover star this month, this time with a huge respect for a judge who has done his job extremely well. In a clear, concise and incredibly sensitive judgment – superbly drafted not only in what it says, but in how he makes inferences about those matters that he doesn't explicitly describe – Peter Jackson J has dealt with what must be one of the most difficult and tragic cases to come before the courts this year.   

The case has been hailed in the headlines as a victory for “the right to be cryogenically frozen” although if the sub-editors had bothered to read this admirably plainly written judgment properly (which you can read here) they would find that Jackson J confirms exactly the opposite.   

There is simply no right of anyone, child or adult, to determine what happens to your own body after you die. Your dead body is not your own property to be disposed of by your will. The decision will always be left in the hands of others.

As an adult you can of course write a will, name your own executors, express your wishes and then hope that you have chosen your executors wisely. Happily, in most cases the people you have nominated will obey your wishes and dispose of your body as you have asked; but if they decide not to comply with your request there is little you can do about it.

The principle of open justice, allowing pubic scrutiny of how citizens come by their deaths, is at the core of the inquest process.  Save in exceptional circumstances[1] Inquests should be heard in open court with the media able to fully report the proceedings.

“The names of those who are born and those who die are rightly a matter of public record.  The fact that someone has died is always a matter of proper public interest and the ability to record it is a normal incident of society.”[2]

Readers will be familiar with Coroners’ powers under Section 39(1) of the Children and Young Persons Act 1933 to restrict reporting of the name of a child who is a witness or an IP. However Coroners have very limited alternative powers to protect the vulnerable who are not themselves an IP or  witness at the inquest.  

In exceptional cases, High Court judges have powers to make or extend a Reporting Restrictions Order (RRO) to protect others, such as family members of the deceased, from unwelcome press attention  (see earlier UK Inquest Law Blog post here re an RRO made in the Court of Protection in anticipation of an inquest).

However another often overlooked provision applicable to Coronial proceedings, and used effectively in a recent inquest, is Section 1 Sexual Offences (Amendment) Act 1992.

R (on the application of Secretary of State for Transport) (Claimant) v HM Senior Coroner for Norfolk (Defendant) & British Airline Pilots Association (Intervener) [2016] EWHC 2279 (Admin)

Readers of the UK Inquest Law Blog need no reminding that prior to the Coroners and Justice Act 2009, coroners had no power to order disclosure of any document so that if disclosure was required, an application had to be made to the High Court. The immediate point for the Divisional Court to decide in this case was the correct interpretation of the powers of coroners to require a person to produce documents (paragraph 2 of Schedule 5 of the 2009 Act). 

The involvement of the Lord Chief Justice indicates that there is a point of general importance.

R (Maxine Hamilton-Jackson) v HM Assistant Coroner for Mid Kent and Medway [2016] EWHC 1796 (Admin) (decision 19.7.16 here)

The absence of opening or closing speeches at inquests means that the need for clarity when summing up is all the more important. The jury must know clearly what they need to find as facts in order to justify any conclusion and, as the Chief Coroner has put it:

“Coroners, however well intentioned, should do their best in directing a jury to avoid using language which is not in everyday use, language which may not be clearly understood”. 

So what are an inquest jury to make of being told they need to decide whether or not there was a failure of a prison system or in the operation of a prison system, by “polarising the dichotomy between: is it mandatory to open an ACCT when a particular event occurs or is it mandatory to open an ACCT when the relevant official considers there is a risk of suicide or self-harm?”

Quashing the jury’s response to just one part of the jury questionnaire in this case, the Divisional Court has held that not only was there a misdirection, because the jury could not be clear what they were being asked to decide, but also re-iterated how the meaning of a policy is not a matter of fact to be determined by the jury, but is a question of law to be determined by the Coroner.

R (Tyrrell) v Senior Coroner for Durham & Darlington [2016] EWHC 1892 (Admin)  

(26.7.16 decision here)

 Around two thirds of the 250 deaths in prison each year are from a naturally occurring cause. In a decision that will be warmly welcomed by Coroners, the Divisional Court has now determined that there is no obligation to hold an Art 2 inquest into such deaths unless there are grounds to believe that there was some failure in the healthcare provided by the state.

This case in which the Claimant’s arguments were described as being advanced at a “high level of legal abstraction” is happily a victory for pragmatism and common sense.   

Were it otherwise Coroners would be obliged to conduct a large number of ‘Article 2 inquests’, to no discernable benefit of anyone and despite it being abundantly clear before the hearing that nothing untoward had taken place.

Burke-Monerville v HM Senior Coroner of Inner North London 

Application for urgent relief  High Court: Fri 8 July

The trend of recent decisions in the High Court has been a general reluctance to hear challenges to coroners' procedural decisions prior to the end of an inquest. Whether the proceedings have or have not been substantively or procedurally unfair is an issue that is best determined after the end of the hearing when the totality of the proceedings and the evidence can be considered.

It is unsurprising therefore that this urgent application for an injunction seeking to prevent an inquest going ahead on a Monday morning was refused in an extempore decision delivered at midnight on Friday.   

Bridget Dolan QC and Jamie Mathieson were counsel to the inquest into the death of Private Cheryl James in 1995 at Deepcut Barracks which ended on 3 June 2016.  The judge’s 100 page findings of fact, addressing the circumstances of the death and the culture and procedures at the camp, can be found here.

John Beggs QC and Cecily White acted for Surrey Police.  Paul Spencer of Serjeants' Inn Chambers also represented a medical witness at the hearings.

R (Tainton) v Senior Coroner for Preston and West Lancashire  [2016] EWHC 1396 (Admin) 16 June 2016

The Court of Appeal in Lewis* made it clear that there is a power, but not a duty, to leave to an inquest jury findings regarding non-causative shortcomings which only may have led to or hastened death.  A coroner has discretion to leave to the jury causes of death that are merely possible and not probable.  

However the Divisional Court have now taken an interesting side-step around Lewis by deciding that, in an Art 2 inquest where a shortcoming has been admitted then, even if it is only possibly causative of the death, the jury should be directed to record it.

“Where the possibility of a violation of the deceased’s right to life cannot be wholly excluded, section 5(1)(b) and 5(2) of the 2009 Act should require the inclusion in the Record of Inquest of any admitted failings forming part of the circumstances in which the deceased came by his death, which are given in evidence before the coroner, even if, on the balance of probabilities, the jury cannot properly find them causative of the death.”[74]

V v Associated Newspapers Ltd and others [2016] EWCOP 21

In November 2015 the Court of Protection determined that an adult woman had the mental capacity to decide whether or not to refuse the life preserving medical treatment offered to her.   She exercised her right to autonomy, refused treatment and died.    

Such capacity decisions are made on a regular basis in the Court of Protection (CoP) – however this particular decision in relation to ‘Ms C’1 has attracted perhaps more widespread media attention than any other Court of Protection case before it.  That reporting has been characterised by the Vice President, Charles J, as:

“reporting that engaged the prurient interest of the public in the personal details of the lives of others, rather than the public interest in important issues relating to [the court’s finding of capacity to decide and its consequences].”   

The back-story of Ms C’s life and her personality is clearly of the type that sells newspapers.  Ms C is now know to many as the “sparkling socialite” and pixelated pictures of her have appeared in both the broadsheet and tabloid press with epithets such as “man-eater” and “obsessed with sex” in the accompanying headlines.  

Reporting restrictions were, unremarkably, made at the time of the original CoP case. However, what makes this case unusual is the family’s subsequent application for the press injunction to be continued after Ms C’s death and to cover press reporting from her inquest. 

Inquests often reveal matters that are of concern but which are unlikely to give rise to a risk of future deaths and so fall outside the reg. 28 “Report on Action to Prevent Future Deaths” provisions (the ‘PFD report’).  Yet it is often overlooked that where the duty to make a PFD report does not arise, the coroner still has another tool in their public health kit and may nevertheless draw attention to a matter of concern arising during the investigation by writing a letter expressing that concern to the relevant person or organisation who can act upon it. 

Known as a ‘Paragraph 37 Letter’ such a step is proposed and approved by the Chief Coroner at paragraph 37 of his Guidance No. 5 (Reports to Prevent Future Deaths); yet it is only rarely used. 

Ewing v Cardiff and Newport Crown Court [2016] EWHC 183 (Admin)

Bereaved friends and other members of the public often take notes of the evidence given in Coroner’s Courts.  Whilst Coroners can dictate much of the practice and procedure within their own courts, the recent case of Ewing in the criminal jurisdiction has clarified that it is only in very limited circumstances that restrictions should be placed on observers taking notes in public hearings and that no express permission to take notes is required.

“Although the Court may, for good reason, withdraw the liberty to take notes, the default position is that anyone who attends a public hearing is free to take notes.”

R (Speck) v HM Coroner for York & (1) NHS England (2) MEDACS (Interested Parties) [2016] EWHC 16   

In a case which serves as a reminder that an inquest should not be seen as a substitute for a public inquiry, the Admin. Court has held that, where a coroner conducting an Art 2 inquest decides that a factor could not even arguably be said to have made any real contribution to the death, then there is no discretion, or indeed power, to investigate that issue.    Coroners’ investigatory powers arise from their statutory duty under the Coroners and Justice Act 2009 s.5 and their discretion is limited to investigating only those factors that might arguably have contributed to a death.

It would be “wrong in principle” to “go into issues of policy and resources with which an inquest should not be concerned”.

Today the Chief Coroner published new guidance on Pre-Inquest Review Hearings (PIRHs) and revised guidance on coroner's conclusions (Guidance No.17 (as amended)). 

The newly published guidance on PIRHs reaffirms the guidance already provided in the cases of: Brown v HM Coroner for Norfolk [2014] Inquest Law Reports 91, Shafi v HM Coroner East London [2015] Inquest Law Reports 154 and Fullick v HM Coroner for Inner London North [2015] EWHC 3522. It encourages: PIRHs in complex cases, circulating agendas in advance and, if relevant, advance notification of the coroner's provisional views on the respective issues. 

The amended guidance on conclusions addresses the sometimes hotly contested questions of (1) what, if any, difference remains in law between a non-Article 2 v. Article 2 conclusion (2) whether a non-Article 2 conclusion is permitted in law to be judgmental and (3) is the coroner’s power in an Article 2 inquest to leave to a jury, for the purposes of a narrative conclusion, possible circumstances restricted to only where those findings will assist the coroner in a PFD report? 

Flower v HM Coroner for Devon, Plymouth, Torbay and South Devon [2015] EWHC 3666 (Admin) 16 December 2015

In a welcome clarification of the extent of a Coroner’s powers to re-open an inquest after having decided not do so, the Divisional Court has confirmed that, where an investigation has been suspended pending criminal proceedings, and a Coroner has determined that it should not be re-opened, the Coroner is not functus officio and so can revisit and change their own decision. Indeed the High Court has no jurisdiction to order an inquest under s13(1)(b) Coroners Act 1988 in such circumstances. 

There had been no inquest and hence there were no inquest findings to quash.

Re Jordan's Applications for JR - Delay & Damages [2015] NICA 66

From the inquest that just keeps on giving a further judgment of the Northern Ireland Court of Appeal (‘NICA’) has been published concerning the award of damages under the Human Rights Act as compensation for the continued delays in bringing to a conclusion the (still unfinished) inquest into the death of Pearse Jordan who was shot by an RUC officer on the Falls Road in 1992.

“The investigation into the death of a close relative, impacts on the next of kin at a fundamental level of human dignity. It is obvious that if unlawful delays occur in an investigation into the death of a close relative that this will cause feelings of frustration, distress and anxiety to the next of kin”. Stephens J

A huge number of legal decisions, including more than 25 Judicial Review applications have already arisen from the procedural inadequacies in investigating this death. In 2001 an award of £10,000 as compensation for the delay up to that point was made by the European Court in Strasbourg, which called into question whether the Northern Irish inquest system was, at the relevant time, structurally capable of providing for both speed and effective access for the deceased’s family. 

R (Fullick) v HM Coroner for Inner London North [2015] EWHC 3522 (Admin) 3 Dec 15

Susan Jones died after falling ill at a police station after she had attended the station voluntarily as a witness.  An alcoholic, homeless and on methadone, she was vulnerable and police statements made it clear that the officers felt they owed her a duty of care: as the Chief Coroner put it, “at the very least she needed looking after”. Having given an interview, Susan was waiting for a specialist team to attend.  While waiting she placed her head on the table and appeared to fall asleep, being heard snoring. She was left for some time, checked once, but not roused. Nearly two hours later, officers realised she was not breathing. An ambulance was called and CPR commenced, but she died in hospital just over a week later.

The Coroner’s initial decision not to hold her inquest with a jury was overturned by the High Court, comprising the Chief Coroner and McCombe LJ.

‘Reason to suspect’ is a low and objective threshold: suspect’ means suspicion: ‘a state of conjecture or surmise.’

Jones v HM Coroner for Gwent and others [2015] EWHC 3178 (Admin) 5 Nov.15

The Divisional Court this week made clear the limits of s.13 Coroners Act 1988 when seeking to overturn and inquest.  Where Judicial Review is the correct vehicle to challenge the decision of a Coroner then the failure to bring such a claim in good time should not be circumvented by an application for a fresh inquest under s.13.

Elberte v Latvia ECtHR App.No. 61243/08 13 April 2015

Next month the Human Transplantation (Wales) Act 2013 comes in to force. Described as the most significant piece of legislation passed by the Welsh Assembly, it will make Wales the first UK country to introduce a ‘soft opt-out’ system for organ and tissue donation. From 1 December 2015 a deemed consent system will operate for organ donation where the presumption will be that people aged 18 or over, who have been resident in Wales for over 12 months, want to donate their organs at their death, unless they have specifically objected.  

This Act has laudable objectives and is anticipated to save countless lives through a 25% rise in the availability of organs for transplant.  

However, those who favour an opt-in system warn of the excesses that can happen if state control and oversight of such a system is lax. Such risks were shown in stark detail in a recent European Court of Human Rights decision involving Latvia, where shocking abuse of a ‘presumed consent’ system was revealed. 

Smith v HM Coroner for Cornwall (2015) 22/10/2015

The important role a coroner’s inquest has to play in elucidating factors relevant to the death in a way that might then allow for the greater protection of the wider public is exemplified by this recent decision of the Divisional Court.  Inquests into two deaths from carbon monoxide poisoning were overturned where full information regarding the knowledge and correction of a design fault in the gas cooker thought to be responsible had neither been available nor explored.

Serjeants’ Inn Chambers recently hosted an evening with Sir Robert Francis QC to discuss and reflect upon the impact of the Duty of Candour, as recommended in the 2013 Francis Report, upon practice in a variety of healthcare areas. Cecily White and Paul Spencer considered the impact in the Coronial jurisdiction of the rather snappily named “Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014”   (ie the Duty of Candour regulations).  Their paper, reproduced here, is summarised below.

Wilson v HM Coroner for Birmingham and Solihull [2015] EWHC 2561 (Admin)

“Fairness in an inquest must be fashioned in an environment where there are no pleadings and in which those given leave to appear as interested persons do not have a case to put. The evidence at inquests often takes an unexpected turn and calls for a degree of flexibility in the procedure to be followed as a consequence. The rules of evidence applied in criminal and civil proceedings do not apply. Questions of fairness to those involved in inquest proceedings must be judged against all these essential features and also in the context that the statutory scheme prohibits a finding of criminal liability on the part of a named person, or of civil liability” 

Burnett LJ

Mr. Wilson, a consultant cardiothoracic surgeon, applied for judicial review of part of the coroner’s conclusions in relation to the deaths of three of his patients having undergone cardiac surgery at his hands. 

Thompson v HM Assistant Coroner for Durham [2015] EWHC 1781 (Admin)

Kristian Thompson was 19 years old when he died.   He was a detained patient in a hospital secure unit under s.3 Mental Health Act. On the day of his death he had suffered an episode of incontinence and went to shower. He was found in the shower, collapsed on the floor with the shower running. He did not recover.

At the inquest in November 2012 the assistant coroner returned an open verdict, recording the medical cause of death as "unascertained". The pathologist and consultant neuro-pathologist involved in the post-mortem and the consultant physician who had been involved in Kristian’s treatment post-collapse considered two possible causes of death (sudden and unexpected death in epilepsy (‘SUDEP’) and sudden adult death syndrome (‘SADS’).  In the absence of an ante-mortem diagnosis of epilepsy the doctors were unable to come to any probable conclusion.  However, the pathologist stated that he would alter his opinion on the cause of death if an expert clinician could diagnose epilepsy at any time.

There had been insufficiency of inquiry such that it was necessary and desirable in the interests of justice to hold a fresh inquest

On 20 August 2015 the Lord Chancellor published revised guidance on civil legal aid funding in inquest cases. It takes into account the conclusions of the Court of Appeal in the case of  Letts v The Lord Chancellor [2015] Inquest Law Reports 15,  and now recognises that there are some categories of case in which the mere fact of death gives rise to a possibility of State responsibility and this suffices to trigger the Article 2 procedural duty to conduct an independent investigation.   

The previous guidance had suggested that an arguable breach of a substantive duty had to be identifiable to engage the need for an Art 2 inquest.   It is now made clear that there are certain categories of death where the automatic duty arises whether or not the evidence in the case discloses an arguable breach of any of the substantive obligations.

Senior Coroner for Cumbria v Ian Smith [2015] EWHC 2465 (Admin)

Poppi Worthington, was only 13 months old when she died in hospital in December 2012 having apparently sustained fractures to her leg and other injuries.   Yet despite there clearly being reason to suspect that this was a violent or unnatural death, and an inquest already having been held, none of the facts surrounding her death have as yet been made public.    Poppi’s inquest in October 2014 took only seven minutes to complete; the Coroner returned an open conclusion and found that her cause of death was ‘unascertained’.   It is hardly surprising then that the High Court has now overturned that first inquest and determined that a fresh inquest should be held.

“The Coroner did not give any information about the circumstances leading to the girl’s death. The inquest did not address questions about her welfare, how she was discovered, whether any attempts were made to revive her and whether any public agencies were at fault.” 

This case re-emphasizes the duty of coroners to hold their inquests fully in public no matter how difficult the surrounding circumstances. Moreover, that this case had to be brought by the present Senior Coroner against the previous Senior Coroner brings into question whether there should be some simpler mechanism than requiring a Senior Coroner to, firstly, seek a fiat of the Attorney General and, secondly, make a High Court application under s.13 Coroner’s Act 1988 when he or she seeks to put right obvious shortcomings and hold a fresh inquest.

Dr S v HM Coroner North Yorkshire East  (Admin Court) Judgment 21 July 2015

Coroners sitting without a jury are now encouraged by the Chief Coroner’s Guidance (no. 17) to deliver a ‘summing up’ in which they state orally, in open court, their key findings of fact before recording their formal inquest conclusions.    But what is to be done when the Coroner oversteps the mark and makes unlawful factual findings or comments during this summing up?  

The case of Dr S is one recent example of a successful Judicial Review challenge to a Coroner’s unlawful comments about a witness’ probity.   However another recent case MRH Solicitor v Manchester County Court EWHC [2015] 1795 raises the question of whether there might be an alternative and simpler mechanism for quashing and striking from the record such findings where the inquest conclusion itself is not challenged. 

The CJA 2009 entered the “terrible twos” this week having come into to force on 25 July 2013.   Its birthday gift was the publication of the ‘Second Annual Report of the Chief Coroner to the Lord Chancellor: 2014-2015’, which details the gradual evolution of the Coroner’s Service as a combination of the CJA 2009 and the efforts of the Chief Coroner lead the service (mostly willingly) into the 21st Century.

R (Wiggins)  v  HM Assistant Coroner Nottinghamshire  [2015] EWHC 1658 (Admin) (26 March 2015) 

With the growing popularity of narrative verdicts in the mid-2000’s it had become common practice for Art 2 inquests to conclude with a lengthy jury narrative outlining a multitude of shortcomings by public bodies.   That practice has largely died out: the Court of Appeal’s decision in R (Lewis) v Mid and North Shropshire Coroner [2009] Inquest LR 294 [2010] 1 WLR 1836, and the more recent Chief Coroner’s Guidance no. 17 on conclusions, have significantly curtailed the number of issues that coroners now direct juries to determine at the end of an Art 2 inquest. That there is no longer any duty for non-causative shortcomings to be recorded has led many coroners to only use their power to do so where they require a jury’s assistance to determine disputed facts as a basis for the coroner’s PFD report.

However a looming case might change the practice yet again as permission has recently been given in Wiggins to bring a judicial review claim addressing the question of whether the causation point in Lewis needs to be re-visited in light of the approach adopted to Art 2 liability in Sarjantson v Chief Constable of Humberside [2013] Inquest LR 251, [2014] QB 411.

HM Coroner for the Isle of Wight v (1) HM Prison Service (2) Family of Alvin Bay (dec) [2015] EWHC 1360 (Admin)   1 April 2015

The sad case of Alvin Bay sets out no new proposition of law, but perhaps leads one to wonder whether there should be some mechanism to allow a Senior Coroner (or even the Chief Coroner) to have a quicker and easier procedure to overturn an inquest conclusion when there is a clear need to do so and no-one is objecting to that action.

In a further court judgment in the long running saga of the investigations of the murder of solicitor Patrick Finucane, Stevens J, in the High Court of Northern Ireland, has held that the decision of the British Government not to hold an public inquiry that could examine the complicity of state agents and employees in his murder was lawful.

"The killing involved the most conspicuously bad, glaring and flagrant breach of the obligation of the state to protect the life of its citizen and to ensure the rule of law."

Stephens J: Finucane’s (Geraldine) Application [2015] NIQB 57