Category: Coroners

Regina v West London Coroner ex parte Gray: CA 1988

Before a coroner’s jury could reach a verdict of unlawful killing, it had to be satisfied ‘that the act or omission of a single person must amount to unlawful conduct which was a substantial cause of death’, although Rule 42 of the Coroners Rules forbids the naming of that person. It was unthinkable that a coroner’s jury should find the commission, although not identifying the offender, of a criminal offence, without being satisfied beyond reasonable doubt.
A suicide verdict is ‘still a drastic action which often leaves in its wake serious social, economic and other consequences’.

Judges:

Watkins LJ

Citations:

[1988] QB 467

Jurisdiction:

England and Wales

Cited by:

Cited – In the Matter of Captain Christopher John Kelly Admn 14-Jun-1996
The deceased was killed by ‘friendly fire’ during a night exercise in Kenya. A verdict of accidental death was returned, and a fresh inquest was sought particularly in the light of a statement from a fellow officer.
Held: The emergence of . .
Approved – Regina v Wolverhampton Coroner ex parte McCurbin CA 1990
The judicial review test is not simply whether there has been an error of law, but also whether the error has or may have resulted in a wrong verdict being entered. . .
Cited – O’Connor, Regina (On the Application of) v HM Coroner for District of Avon and Another Admn 7-May-2009
Two children died when their father jumped with them from a hotel balcony. The father had been acquitted in Crete of manslaughter after evidence of his psychiatric condition. The applicant now challenged the English coroner’s verdict of unlawful . .
Cited – Braganza v BP Shipping Ltd and Others CA 22-Mar-2013
The claimant widow sued in negligence after the disappearance overboard of her husband from the respondent’s ship. The court had found insufficient evidence to establish the cause of death, either as to negligence as suggested by the claimant, or as . .
Cited – Braganza v BP Shipping Ltd and Another ComC 30-May-2012
The claimant said that her husband, serving as an officer on the defendant’s ship was lost overboard as a result of the defendant’s negligence.
Held: The claim under the 1976 Act failed, but the court awarded the contractual sum claimed.
Cited – Braganza v BP Shipping Ltd SC 18-Mar-2015
The claimant’s husband had been lost from the defendant’s ship at sea. The defendant had contracted to pay compensation unless the loss was by suicide. They so determined. The court was now asked whether that was a permissible conclusion in the . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 31 July 2022; Ref: scu.187754

Takoushis, Regina (on the Application of) v HM Coroner for Inner North London: Admn 16 Dec 2004

A patient suffering schizophrenia had been a voluntary patient. He was allowed to visit another unit within the hospital grounds, but then left altogether and was next found preparing to jump from Tower Bridge. He was taken by ambulance to Hospital but, left to wait, he again left, and a person of his description was seen shortly afterwards to jump into the river at St Katherine’s Dock and some weeks later his body was recovered from the river at Wapping. Mrs Takoushis applied for judicial review of the inquest. She said that the enquiry had been insufficient to satisfy the requirements of article 2 of the ECHR because the Coroner had refused to allow her to call expert evidence relating to the quality of care that her husband had received at the hospital prior to his death. The hospital took part in the proceedings as an interested party.
Held: The judge noted that the hospital had accepted that article 2 was engaged. In view of that it was not necessary for him to pursue that point.
Sir Anthony Clarke MR said: ‘Although the possible verdicts at an inquest under the 1988 Act are circumscribed and, in particular must not ascribe criminal or civil liability, that does not mean that the facts should not be fully investigated . .’

Judges:

Elias J

Citations:

[2004] EWHC 2922 (Admin)

Links:

Bailii

Statutes:

Coroners Act 1988, European Convention on Human Rights 2

Jurisdiction:

England and Wales

Citing:

Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.

Cited by:

Appeal from – Takoushis, Regina (on the Application of) v HM Coroner for Inner North London and others CA 30-Nov-2005
Relatives sought judicial review of the coroner’s decision not to allow a jury, and against allowance of an expert witness. The deceased had been a mental patient but had been arrested with a view to being hospitalised. He was taken first to the . .
Cited – Goodson v HM Coroner for Bedfordshire and Luton and Another (No 2) CA 12-Oct-2005
The applicant intended to appeal refusal of her challenge to the verdict of the coroner. For the first time at appeal she sought a protective costs order.
Held: The Corner House case established that a request for a protective costs order . .
Cited – Gentle, Regina (on the Application of) and Another v The Prime Minister and Another HL 9-Apr-2008
The appellants were mothers of two servicemen who had died whilst on active service in Iraq. They appealed refusal to grant a public inquiry. There had already been coroners inquests. They said that Article 2 had been infringed.
Held: The . .
Cited – Hurst, Regina (on the Application of) v Commissioner of Police of the Metropolis v London Northern District Coroner HL 28-Mar-2007
The claimant’s son had been stabbed to death. She challenged the refusal of the coroner to continue with the inquest with a view to examining the responsibility of any of the police in having failed to protect him.
Held: The question amounted . .
Cited – Savage v South Essex Partnership NHS Foundation Trust (MIND intervening) HL 10-Dec-2008
The deceased had committed suicide on escaping from a mental hospital. The Trust appealed against a refusal to strike out the claim that that they had been negligent in having inadequate security.
Held: The Trust’s appeal failed. The fact that . .
Lists of cited by and citing cases may be incomplete.

Coroners, Human Rights

Updated: 28 July 2022; Ref: scu.221032

Lewis, Regina (On the Application of) v HM Coroner for the Mid and North Division Of the County Of Shropshire and Another: Admn 3 Apr 2009

Citations:

[2009] EWHC 661 (Admin)

Links:

Bailii

Jurisdiction:

England and Wales

Cited by:

Appeal From – Lewis, Regina (on The Application of) v HM Coroner for The Mid and North Division of The County of Shropshire and Another CA 21-Dec-2009
The claimant’s son was found hanging in his prison cell. He appealed refusal of a judicial review of the coroner’s decision not to put to the jury a question as to certain possible causative matters. The youth was seen hanging, but the guard called . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 24 July 2022; Ref: scu.341532

Williams v The United Kingdom: ECHR 24 Jun 2008

The claimant’s son had died at the tragedy at Hillsborough football stadium. A senior police officer had opened a gate to allow into enclosures already full, a further 2000 fans. 96 fans died in the resulting crush. The coroner had refused to allow the enquiry to extend beyond events before 3:15pm, saying that evidence, inter alia from the Taylor Inquiry, was that any fans still alive and who dies after that time had already suffered injuries which would make their deaths inevitable. The claimant said that several people remained alive, and that the inquest by that decision had not considered actions which might have saved lives. Some police officers said thaty had been presurised to remove criticisms of their force, and there was medical evidence to support the suggestion that several remained alive after the 3:15pm cut-off.
Held:

Judges:

Lech Garlicki P

Citations:

10170/02, [2008] ECHR 748

Links:

Bailii

Statutes:

European Convention on Human Rights

Human Rights, Coroners

Updated: 19 July 2022; Ref: scu.272595

In re LM (Reporting Restrictions: Coroner’s Inquest): FD 1 Aug 2007

An application was made for an injunction to control reporting of a coroner’s inquest to protect the interests of children of the deceased.
Held: Coroners’ inquests are subject to the same controls as other courts for the purposes of controlling media reports. In this case it was permissibe to report the names and addresses of the deceased and his wife, but the media could not report in any way which alluded to the existence of LM.

Judges:

Sir Mark Potter P

Citations:

Times 20-Nov-2007

Jurisdiction:

England and Wales

Coroners, Media, Children

Updated: 17 July 2022; Ref: scu.261775

Borrows v HM Coroner for Preston: QBD 15 May 2008

The family members disputed who should have custody of the deceased’s body and the right to make arrangements for the funeral.

Judges:

Cranston J

Citations:

[2008] EWHC 1387 (QB), [2008] EWHC 1387 (Admin), [2008] Fam Law 984, [2008] 2 FLR 1225

Links:

Bailii

Statutes:

Cremation Regulations 1930 8

Jurisdiction:

England and Wales

Cited by:

Cited – Re JS (Disposal of Body) FD 10-Nov-2016
Child’s Wish for post-mortem cryonic Preservation
JS, a child of 14, anticipating her death from cancer expressed the desire that her body should receive cryonic preservation in the hope that one day a treatment might be available to allow her to be revived, and proceedings were issued. Her parents . .
Lists of cited by and citing cases may be incomplete.

Wills and Probate, Human Rights, Coroners

Updated: 17 July 2022; Ref: scu.270485

Assistant Deputy Coroner for Inner West London v Channel 4 Television Corporation: QBD 31 Oct 2007

The coroner investigating the death of Prncess Diana sought an order for the production by Channel 4 of documents and materials in its possession.
Held: Whilst the order should be made, it must be recognised that the Civil Procedure Rules were designed for use within an adversarial context, and not within the context of the inquisatorial context of an inquest, and such orders should be made with care.

Judges:

Eady J

Citations:

[2007] EWHC 2513 (QB), Times 11-Dec-2007, Protection from Harassment Act 1997

Links:

Bailii

Jurisdiction:

England and Wales

Coroners

Updated: 15 July 2022; Ref: scu.261563

Regina (on the appication of Gentle and Clarke) v The Prime Minister; Secretary of Sate for Defence; Attornery General: CA 12 Dec 2006

The mothers of two servicemen who had died whilst on service in the war in Iraq challenged refusal to hold an independent inquiry into the circumstances leading to the invasion of Iraq.
Held: The appeal failed.

Judges:

Sir Anthony Clarke MR, Sir Igor Judfe P, Dyson LJ

Citations:

[2006] EWCA Civ 1689, [2007] 2 WLR 195, [2007] QB 689, [2007] HRLR 10

Links:

Bailii

Jurisdiction:

England and Wales

Citing:

Appeal from – Gentle and Others, Regina (on the Application of) v the Prime Minister and others Admn 20-Dec-2005
The applicants sought leave to bring judicial review of the decisions which led to the invasion of Iraq. They were relatives of servicemen who had died there.
Held: The court’s only duty at this stage was to ask whether there was an arguable . .

Cited by:

Appeal from – Gentle, Regina (on the Application of) and Another v The Prime Minister and Another HL 9-Apr-2008
The appellants were mothers of two servicemen who had died whilst on active service in Iraq. They appealed refusal to grant a public inquiry. There had already been coroners inquests. They said that Article 2 had been infringed.
Held: The . .
Lists of cited by and citing cases may be incomplete.

Armed Forces, Coroners, Human Rights

Updated: 14 July 2022; Ref: scu.267534

Al Fayed, Regina (on the Application of) v Assistant Deputy Coroner of Inner West London: Admn 10 Apr 2008

The court gave its reasons for an earlier refusal of permission to apply for judicial review of a coroner’s decision refusing permission to require the attendance of his Royal Highness the Duke of Edinburgh, and to ask questions of the Queen in the course of the inquest into the death of Diana, Princess of Wales. Whilst it was not suggested that they had had any direct involvement the applicant wished to enquire to see whether there was encouraged an atmosphere in which actions against Diana may have occurred.
Held: The Coroner’s approach was neither illogical nor unreasonable, and his conclusion was not flawed. He was required to make a judgment based on whether it was expedient in the particular context of the facts and issues relevant to these inquests. In that context he was entitled to have regard to the vast amount of evidence which had been called and the very limited evidence which remained to be called. As he put it: ‘in keeping open the question whether it might be expedient to call the Duke of Edinburgh I was anxious to see what evidence emerged during the inquests that might alter my initial view. Looking at the whole of the evidence and keeping firmly in mind that it is for the jury and not me to decide what evidence is to be accepted or rejected, nothing has emerged to persuade me it will be expedient to call the Duke of Edinburgh . . Inquiries of Her Majesty The Queen should not be made as suggested by Mr Al Fayed on the basis that they will not assist the jury to answer the statutory questions.’

Judges:

Sir Igor Judge P QBD, Gross, Walker JJ

Citations:

[2008] EWHC 713 (Admin)

Links:

Bailii

Jurisdiction:

England and Wales

Coroners

Updated: 14 July 2022; Ref: scu.266891

Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset: Admn 14 Dec 2001

The deceased had committed suicide whilst in prison. It was argued that the prison should have recognised that he was a suicide risk, and acted accordingly. The coroner had requested a note from the jury as to the cause of death. The court considered whether a coroner’s inquest satisfied the requirements for an investigation of a death in custody: ‘However, where there has been neglect on the part of the State, and that neglect was a substantial contributory cause of the death, my view is that a formal and public finding of neglect on the part of the State is in general necessary in order to satisfy those requirements [of article 2].’ An inquest would not necessarily satisfy the procedural requirements of article 2 in such a case, but the court declined to order that the jury’s note be incorporated in the inquisition, because inter alia the coroner had acted unlawfully in suggesting production of the note. No declaration was needed but, at the request of the Secretary of State, declared that: ‘by reason of the restrictions on the verdict at the inquest into the death of [the deceased] . . . that inquest was inadequate to meet [the] procedural obligation in Article 2 of the European Convention . . .’

Judges:

Stanley Burnton J

Citations:

[2001] EWHC Admin 1043

Statutes:

European Convention on Human Rights 2

Jurisdiction:

England and Wales

Citing:

Cited – Regina v Walthamstow Coroner, Ex parte Rubenstein 19-Feb-1982
The 1988 Act was a consolidating Act. . .
Cited – Regina v HM Coroner for Birmingham, Ex parte Secretary of State for the Home Department 1990
. .
Cited – Regina v Coroner for Western District of Sussex Ex Parte Homberg Roberts and Mannerss QBD 27-Jan-1994
A Coroner’s enquires should be as to ‘how’ the death arose, and not into all the circumstances contributing to the death.
Simon Brown LJ said: ‘It is clear that the coroner’s over-riding duty is to inquire ‘how’ the deceased came by his death . .

Cited by:

Appeal from – Regina (Amin) v Secretary of State for the Home Department; Regina (Middleton) v Coroner for West Somersetshire CA 27-Mar-2002
A prisoner had been killed in his cell by a cell-mate known to be unstable and racist. His family sought to be involved in the inquiry into the death within the prison system. A second prisoner hanged himself in his cell. His family alleged that he . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Lists of cited by and citing cases may be incomplete.

Prisons, Coroners, Human Rights

Updated: 14 July 2022; Ref: scu.194501

Bennett, Regina (on the Application of) v HM Coroner for Inner South London and others: CA 26 Jun 2007

The deceased had been shot by the police, who mistakenly believed him to be armed. Judicial review was sought saying that the coroner had wrongly refused to leave to the jury the possible verdict of unlawful killing.
Held: The appeal was dismissed. Whilst the jury should be trusted to intepret the facts, a coroner could properly not leave a possible verdict to the jury where the verdict would, on the evidence, be perverse. Considerations of what might or might not have been admissible evidence at a criminal trial were irrelevant.

Judges:

Waller LJ, Keene LJ, Dyson LJ

Citations:

[2007] EWCA Civ 617, Times 13-Aug-2007

Links:

Bailii

Jurisdiction:

England and Wales

Citing:

Cited – Regina v Galbraith CCA 1981
Rejection of Submission of No Case to Answer
The defendant had faced a charge of affray. The court having rejected his submission of having no case to answer, he had made an exculpatory statement from the dock. He appealed against his conviction.
Held: Lord Lane LCJ said: ‘How then . .
Cited – Bubbins v United Kingdom ECHR 17-Mar-2005
The deceased had returned home drunk, and climbed in through a window. His girlfriend saw only his legs and reported an intruder to the police. He refused to identify himself when challenged by the police and on pointing a gun from the window he was . .
Cited – McCann and Others v The United Kingdom ECHR 6-Oct-1995
Wrong assumptions made by police officers in the killing of terrorists amounted to a human rights breach, despite the existence of danger to the public of an imminent attack. Article 2(1) is ‘one of the most fundamental provisions in the . .
Cited – Regina v HM Coroner for Exeter and East Devon ex parte Palmer 10-Dec-1997
Lord Woolf discussed the role of the coroner acting as a filter to avoid injustice: ‘In a difficult case, the Coroner is carrying out an evaluation exercise. He is looking at the evidence before him as a whole and saying to himself, without deciding . .
Cited – Sharman, Regina (on the Application of) v HM Coroner for Inner North London Admn 12-May-2005
A caller reported to the police that a man had left a public house with a gun in a plastic bag. He was confronted by armed police and shot. It had in fact been a stick of wood. The officers appealed a finding of unlawful killing.
Held: The . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 11 July 2022; Ref: scu.253740

Antoniou, Regina (on The Application of) v Central and North West London NHS Foundation Trust and Others: Admn 10 Oct 2013

The patient had died while detained in a mental hospital. Held There was no need to conduct an immediate independent investigation before the inquest.

Judges:

Aikens LJ, Mitting J

Citations:

[2013] EWHC 3055 (Admin), [2015] 1 WLR 4459, [2013] Med LR 536, [2013] WLR(D) 379, (2014) 135 BMLR 89

Links:

Bailii, WLRD

Statutes:

Coroners and Justice Act 2009

Jurisdiction:

England and Wales

Coroners, Human Rights

Updated: 11 July 2022; Ref: scu.516454

Jordan v Lord Chancellor and Another (Northern Ireland): HL 28 Mar 2007

In each case a death had occurred many years earlier where the deceased had apparently died at the hands of the armed forces. The relatives now challenged the range of verdicts which could be left to a coroner’s jury.
Lord Bingham said: ‘The Coroner must decide how widely the inquiry should range to elicit the facts pertinent to the circumstances of the death and responsibility for it. This may be a very difficult decision, and the inquiry may, as pointed out above, range more widely than the verdict or findings.’ Jamieson still remains authoritative in respect of both (i) inquests into deaths that occurred before 2nd October 2000 (the date that the HRA 1998 came into force) and (ii) inquests into deaths that occur after that date, except where re-interpretation of the 1988 Act and the 1984 Rules in accordance with the ruling in Middleton is required to avoid violation of a party’s right to an Article 2 compliant investigation, as follows: ‘ The decision of the House . . Hurst . . makes plain the answers to these questions. I summarise the answers very briefly. . . (3) No. Jamieson was approved by the House in Middleton. It continues to apply to inquests into deaths occurring before 2 October 2000 and to inquests into deaths occurring after that date save where re-interpretation of the relevant legislation and rules in accordance with the ruling of the House in Middleton is called for to avoid violation of a party’s Convention right to an investigation meeting the requirements of article 2 of the Convention . . (4) No. Jamieson should not be overruled.’

Judges:

Lord Bingham of Cornhill, Lord Rodger of Earlsferry, Baroness Hale of Richmond, Lord Brown of Eaton-under-Heywood, Lord Mance

Citations:

[2007] UKHL 14, [2007] 2 WLR 754, [2007] 2 AC 226

Links:

Bailii

Jurisdiction:

Northern Ireland

Citing:

See Also – Jordan, Re an Application for Judicial Review QBNI 29-Jan-2002
The claimant challenged the Lord Chancellor’s failure to introduce legislation to ensure that the coroners’ system in Northern Ireland comprised with Human Rights Law. . .
See Also – Re Jordan’s Application QBNI 8-Mar-2002
The claimant challenged a ruling of the coroner on 9 January 2002 that he would conduct the inquest on the basis of existing law and practice and would not leave to the jury the option of returning a verdict of unlawful killing. . .
At ECHR – Stephen Jordan (No 2) v The United Kingdom ECHR 10-Dec-2002
The applicant was a soldier who had been court marshalled for misuse of travel warrants. He wished to use in his defence his recent epilepsy. There was some delay while medical reports were obtained, and subsequently when the new legal system was . .
Cited – Stephen Jordan (No 2) v The United Kingdom ECHR 10-Dec-2002
The applicant was a soldier who had been court marshalled for misuse of travel warrants. He wished to use in his defence his recent epilepsy. There was some delay while medical reports were obtained, and subsequently when the new legal system was . .
Cited – McCaughey and Another, Re Application for Judicial Review QBNI 20-Jan-2004
Application by the fathers of Martin McCaughey and Desmond Grew, who were killed by soldiers on 9 October 1990, for Judicial Review of the decisions of the Chief Constable and the Coroner concerning the disclosure of documents for the purposes of . .
See Also – Police Service of Northern Ireland v McCaughey and Another CANI 14-Jan-2005
. .
Cited – McCaughey, Re Application for Judicial Review CANI 6-Apr-2006
. .

Cited by:

Cited – McCaughey and Another, Re Application forJudicial Review SC 18-May-2011
The claimants sought a fuller inquest into deaths at the hands of the British Army in 1990 in Northern Ireland. On opening the inquest, the coroner had declined to undertake to hold a hearing compliant with article 2, and it had not made progress. . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 10 July 2022; Ref: scu.251023

Paul and others v Deputy Coroner of the Queen’s Household and Another: Admn 2 Mar 2007

The applicants sought judicial review of preliminary directions given for the intended inquest on the deaths of Diana Princess of Wales and of Dodi Al Fayed. It was submitted that the jurisdiction had been wrongly transferred to the Queen’s Coroner under section 14.
Held: under the 1988 Act, the Coroner for the Queen’s household was subject to all the general duties imposed and had all the general powers granted by the Act. Furthermore, since he was a franchise coroner, the area in which he exercised his jurisdiction was and could only have been the palaces or houses where Her Majesty was residing. Though this was a road traffic accident, its circumstances were unusual, and the fact of being chased by paparazzi disclosed a risk of similar future accidents. This brought in the requirement that a jury should sit. The fact that the family of the deceased wanted a jury was relevant but not determinatve. Since the inquest was to be with a jury, and it had been agreed that it would be inappropriate for such a jury to be drawn from members of the Queen’s household, the coroner should not have accepted jurisdiction as the Queen’s Coroner. Her impartiality had not however been compromised, and she should sit as deputy coroner for Surrey and with a jury.

Judges:

Smith LJ, Collins J, Silber J

Citations:

[2007] EWHC 408 (Admin), Times 12-Mar-2007, [2007] 2 All ER 509, [2007] 3 WLR 503, [2008] QB 172

Links:

Bailii

Statutes:

Coroners Act 1988 14 29

Citing:

Cited – Regina v Her Majesty’s Coroner at Hammersmith ex parte Peach CA 1980
A coroner was obliged to sit with a jury under the section 13(2) of the 1926 Act where the deceased, who was watching a demonstration, was struck a violent blow on the back of his head from which he died.
Bridge LJ said: ‘The key to the nature . .
Cited – Regina v HM Coroner for the Eastern District of the Metropolitan County of West Yorkshire ex parte National Union of Mineworkers CA 1985
A union picket had been knocked down by a lorry
Held: The coroner had been correct not to summon a jury pursuant to the section. It was of crucial importance that the facts did not have ‘any particular feature which distinguishes it from any . .
Cited – Porter and Weeks v Magill HL 13-Dec-2001
Councillors Liable for Unlawful Purposes Use
The defendant local councillors were accused of having sold rather than let council houses in order to encourage an electorate which would be more likely to be supportive of their political party. They had been advised that the policy would be . .
Cited – In Re Neal (Coroner: Jury) QBD 17-Nov-1995
The father of the deceased sought to have the coroner quash the inquest. His daughter had died in Spain from carbon monoxide poisoning, apparently emanated from a faulty water heater in the apartment in which she had stayed. Her body had been . .

Cited by:

See Also – Assistant Deputy Coroner of Inner West London v Paul and Another, Regina on the Application of CA 28-Nov-2007
The coroner appealed a judicial review granted after he allowed into evidence, hearsay evidence contained in a written statemnent from a witness who could not attend the inquest.
Held: Rule 37 does not allow the admission of a document, even . .
Cited – Lewis v Commissioner of Police of The Metropolis and Others (Rev 1) QBD 31-Mar-2011
The defendant sought a ruling on the meaning of the words but using section 69(4) of the 1981 Act. The claimant solicitor was acting in complaints as to the unlawful interception of celebrity voicemails by agents of the press. There had been debate . .
Cited – Shafi v HM Senior Coroner for East London Admn 20-Jul-2015
The claimant’s son had died in a prison attached to a police station in Dubai. She sought a new inquest saying that the first had been inadequate.
Held: A new inquest was ordered. There had been difficulties in that the Dubai authorities had . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 10 July 2022; Ref: scu.249381

In the Matter of Captain Christopher John Kelly: Admn 14 Jun 1996

The deceased was killed by ‘friendly fire’ during a night exercise in Kenya. A verdict of accidental death was returned, and a fresh inquest was sought particularly in the light of a statement from a fellow officer.
Held: The emergence of fresh evidence, even if it is in part evidence which should have disclosed to the Coroner at the inquest, is not determinative of the question whether there should be another inquest. The court was not persuaded that the interests of justice called for a fresh inquest.

Judges:

Lord Justice Pil,l Mr Justice Newman

Citations:

[1996] EWHC Admin 15

Statutes:

Coroners Act 1988 8(3)(d)

Jurisdiction:

England and Wales

Citing:

Cited – Regina v West London Coroner ex parte Gray CA 1988
Before a coroner’s jury could reach a verdict of unlawful killing, it had to be satisfied ‘that the act or omission of a single person must amount to unlawful conduct which was a substantial cause of death’, although Rule 42 of the Coroners Rules . .
Cited – Regina v South London Coroner ex parte Thompson 8-Jul-1982
The court discussed the function of the coroner and his inquest.
Lord Lane CJ said: ‘The coroner’s task in a case such as this is a formidable one, and no one would dispute that; that is quite apart from the difficulties which inevitably arise . .
Cited – In re Rapier (Deceased) QBD 1988
A young prisoner had been found dead in his cell hanging. A report suggested that he may have been sniffing solvents. The coroner himself initiated proceedings both under the Coroners’ Act and for judicial review to quash the inquisition over which . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .

Cited by:

Cited – Regina on the Application of Mullholland v HM Coroner for St Pancras QBD 7-Nov-2003
The applicant sought to re-open a coroner’s inquest. The deceased had been drunk, slipped banged his head and fallen to the ground. Police and ambulance were called. The ambulance worker was not told he had been unconscious, and he was taken to the . .
Lists of cited by and citing cases may be incomplete.

Coroners, Armed Forces

Updated: 10 July 2022; Ref: scu.136563

Regina v HM Coroner for Exeter and East Devon ex parte Palmer: 10 Dec 1997

Lord Woolf discussed the role of the coroner acting as a filter to avoid injustice: ‘In a difficult case, the Coroner is carrying out an evaluation exercise. He is looking at the evidence before him as a whole and saying to himself, without deciding matters which are the province of the jury, ‘Is this a case where it would be safe for the jury to come to the conclusion that there had been an unlawful killing?’ If he reaches the conclusion that, because the evidence is so inherently weak, vague or inconsistent with other evidence, it would not be safe for a jury to come to the verdict, then he has to withdraw the issue from the jury.’

Judges:

Lord Woolf

Citations:

Unreported, 10 December 1997

Jurisdiction:

England and Wales

Cited by:

Cited – Sharman, Regina (on the Application of) v HM Coroner for Inner North London Admn 12-May-2005
A caller reported to the police that a man had left a public house with a gun in a plastic bag. He was confronted by armed police and shot. It had in fact been a stick of wood. The officers appealed a finding of unlawful killing.
Held: The . .
Cited – Bennett, Regina (on the Application of) v HM Coroner for Inner South London and others CA 26-Jun-2007
The deceased had been shot by the police, who mistakenly believed him to be armed. Judicial review was sought saying that the coroner had wrongly refused to leave to the jury the possible verdict of unlawful killing.
Held: The appeal was . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 09 July 2022; Ref: scu.258849

Kasperowicz, Regina (on the Application of) v HM Coroner for Plymouth: CA 10 Jan 2005

Renewed application for leave to challenge to an order for a post-mortem examination. The deceased had died aged 88.
Held: No doctor had recently attended the deceased, and a post mortem was required at law. Leave was refused. It was for the coroner to address as best he could within the law the humanitarian concerns of the family.

Citations:

[2005] EWCA Civ 44

Links:

Bailii

Statutes:

Births and Deaths Registration Act 1953 22(1)

Jurisdiction:

England and Wales

Coroners

Updated: 08 July 2022; Ref: scu.245560

McCaughey, Re Application for Judicial Review: CANI 6 Apr 2006

Citations:

[2006] NICA 13

Links:

Bailii

Jurisdiction:

Northern Ireland

Cited by:

Cited – Jordan v Lord Chancellor and Another (Northern Ireland) HL 28-Mar-2007
In each case a death had occurred many years earlier where the deceased had apparently died at the hands of the armed forces. The relatives now challenged the range of verdicts which could be left to a coroner’s jury.
Lord Bingham said: ‘The . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 05 July 2022; Ref: scu.240124

Goldstein, Regina (on The Application of) v Her Majesty’s Coroner for Inner London District Greater London: Admn 16 Jul 2014

Application to discharge injunction against a postmortem. The family wanted a non-invasive post-mortem for religious reasons.
Held: The court made an order (in the case as here where there was no suspicion of foul play) which would go some way to respecting the deceased’s religion, as follows: ‘1) non-invasive procedures performed by Professor Roberts;
2) minimally invasive procedures performed by Professor Roberts, should he consider that they are necessary;
3) a fully invasive traditional autopsy performed by Professor Roberts, should he consider that necessary to ascertain the cause of death.’

Judges:

Mitting J, Thornton HHJ

Citations:

[2014] EWHC 3889 (Admin)

Links:

Bailii

Jurisdiction:

England and Wales

Coroners

Updated: 04 July 2022; Ref: scu.551942

Re Jordan’s Application: QBNI 8 Mar 2002

The claimant challenged a ruling of the coroner on 9 January 2002 that he would conduct the inquest on the basis of existing law and practice and would not leave to the jury the option of returning a verdict of unlawful killing.

Judges:

Kerr J

Citations:

[2002] NIQB 20

Jurisdiction:

Northern Ireland

Citing:

See Also – Jordan, Re an Application for Judicial Review QBNI 29-Jan-2002
The claimant challenged the Lord Chancellor’s failure to introduce legislation to ensure that the coroners’ system in Northern Ireland comprised with Human Rights Law. . .

Cited by:

See Also – Jordan v Lord Chancellor and Another (Northern Ireland) HL 28-Mar-2007
In each case a death had occurred many years earlier where the deceased had apparently died at the hands of the armed forces. The relatives now challenged the range of verdicts which could be left to a coroner’s jury.
Lord Bingham said: ‘The . .
See Also – Stephen Jordan (No 2) v The United Kingdom ECHR 10-Dec-2002
The applicant was a soldier who had been court marshalled for misuse of travel warrants. He wished to use in his defence his recent epilepsy. There was some delay while medical reports were obtained, and subsequently when the new legal system was . .
Cited – Jordan, Re an Application for Judicial Review QBNI 12-Jan-2004
. .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 04 July 2022; Ref: scu.272805

Regina v HM Coroner for Portsmouth Ex parte Keene (John): QBD 1989

The applicant challenged the coroner’s conduct of the inquest saying it had been carried out in a perfunctory manner.
Held: Even though the coroner was aware of information tending to a particular verdict, the inquest should be carried out properly. The coroner had not done this, but no doubt had been cast on the verdict itself, and no rehearing was ordered.

Judges:

Pill J

Citations:

(1989) 153 JP 658, [1990] COD 7, (1989) 153 JPN 706 (DC), Guardian 24-Jun-1989

Jurisdiction:

England and Wales

Cited by:

Cited – Regina v Coroner for Southern District of Greater London, ex Parte Driscoll Admn 22-Oct-1993
The applicant, a sister of the deceased, requested a judicial review of the decision of the coroner not to allow her to be represented and to cross examine witnesses.
Held: One of the coroner’s letters had been offensive and misleading. A . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 03 July 2022; Ref: scu.229166

PSNI (Leave Stage), Re Judicial Review: QBNI 27 May 2010

Application for declaratory relief sought by the Chief Constable of the Police Service of Northern Ireland with respect to the correct approach to be adopted to the disclosure of materials in Coronial inquests particularly where an application for Public Interest Immunity might require to be brought. The issue in the instant case had arisen in the context of deaths described by the Senior Coroner for Northern Ireland as those which ‘might be labelled as controversial deaths occurring during the course of the height of the troubles’ involving an issue as to whether or not any of the deaths were caused as a consequence of an intention to kill on the part of the security forces.

Citations:

[2010] NIQB 91

Links:

Bailii

Jurisdiction:

Northern Ireland

Coroners

Updated: 01 July 2022; Ref: scu.424810

Jordan, Re an Application for Judicial Review: QBNI 29 Jan 2002

The claimant challenged the Lord Chancellor’s failure to introduce legislation to ensure that the coroners’ system in Northern Ireland comprised with Human Rights Law.

Judges:

Kerr J

Citations:

[2002] NIQB 7, [2002] NI 151

Jurisdiction:

Northern Ireland

Cited by:

See Also – Jordan v Lord Chancellor and Another (Northern Ireland) HL 28-Mar-2007
In each case a death had occurred many years earlier where the deceased had apparently died at the hands of the armed forces. The relatives now challenged the range of verdicts which could be left to a coroner’s jury.
Lord Bingham said: ‘The . .
See Also – Re Jordan’s Application QBNI 8-Mar-2002
The claimant challenged a ruling of the coroner on 9 January 2002 that he would conduct the inquest on the basis of existing law and practice and would not leave to the jury the option of returning a verdict of unlawful killing. . .
See Also – Stephen Jordan (No 2) v The United Kingdom ECHR 10-Dec-2002
The applicant was a soldier who had been court marshalled for misuse of travel warrants. He wished to use in his defence his recent epilepsy. There was some delay while medical reports were obtained, and subsequently when the new legal system was . .
See Also – Jordan, Re an Application for Judicial Review QBNI 12-Jan-2004
. .
Lists of cited by and citing cases may be incomplete.

Armed Forces, Coroners, Human Rights

Updated: 01 July 2022; Ref: scu.272804

Commissioner of Police for the Metropolis v Hurst: CA 21 Jul 2005

The Commissioner appealed an order requiring the North London Coroner to re-open an inquest into a death of Mr Hurst. Following the adjournment a neighbour had been convicted of the murder. The commissioner argued that since the death had occurred before the coming into effect of the Human Rights Act, the coroner was not under the same duty to hold an inquest.
Held: The duty to apply a convention applied before its incorporation into English law under the 1998 Act, and particularly so where there was a discretion being exercised. Had the coroner taken those obligations into account, he would have ordered an inquest. McKerr had considered only obligations as created by the 1998 Act, not those which had existed before it. The coroner was to be required to re-open the inquest.

Judges:

Buxton, Sedley LJJ, Sir Martin Nourse

Citations:

[2005] EWCA Civ 890, Times 11-Aug-2005

Links:

Bailii

Statutes:

Coroners Act 1988 16(1), Human Rights Act 1998

Jurisdiction:

England and Wales

Citing:

Cited – Regina v Lyons, Parnes, Ronson, Saunders HL 15-Nov-2002
The defendants had been convicted on evidence obtained from them by inspectors with statutory powers to require answers on pain of conviction. Subsequently the law changed to find such activity an infringement of a defendant’s human rights.
Cited – In re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
Lists of cited by and citing cases may be incomplete.

Police, Coroners, Human Rights

Updated: 01 July 2022; Ref: scu.228941

Plymouth City Council v HM Coroner for the County of Devon and Another: Admn 27 May 2005

The local authority in whose care the deceased child had been held challenged a decision by the coroner not to limit his inquiry to the last few days of the child’s life. The coroner had decided that he had an obligation to conduct a wider enquiry under the 1968 Act.
Held: ‘The central question in the case is narrow, namely whether the child protection agencies, in particular Plymouth, arguably knew or ought to have known of a real and immediate risk to Perrin’s life. ‘ It was not whether a care order should have been sought. The coroner had looked to the wrong question, and the decision was quashed.

Judges:

Wilson J

Citations:

[2005] EWHC 1014 (Admin), [2005] 2 FCR 428

Links:

Bailii

Statutes:

Human Rights Act 1998

Jurisdiction:

England and Wales

Citing:

Cited – Calvelli and Ciglio v Italy ECHR 17-Jan-2002
The applicants’ baby had died shortly after birth in 1987. They complained about the medical care. The complaint was not investigated speedily by the authority, resulting in a criminal complaint becoming time barred after a conviction in 1994 was . .
Cited – Edwards v The United Kingdom ECHR 14-Mar-2002
The deceased, a young man of mixed race, had been placed in a cell with another prisoner who was known to be violent, racist, and mentally unstable. The staff knew that the panic button was defective. The deceased was murdered by his cell-mate. His . .
Cited – Amin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
Prisoner’s death – need for full public enquiry
The deceased had been a young Asian prisoner. He was placed in a cell overnight with a prisoner known to be racist, extremely violent and mentally unstable. He was killed. The family sought an inquiry into the death.
Held: There had been a . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Khan, Regina (on the Application of) v Secretary of State for Health CA 10-Oct-2003
The claimant’s child had died as a result of negligence in hospital. The parents had been told the result of police investigation and decision not to prosecute, and the hospital’s own investigation, but had not been sufficiently involved. There . .
Cited – Hurst v Coroner Northern District of London Admn 4-Jul-2003
The deceased was killed by Mr Reid, a neighbour, who was convicted of his manslaughter.
Held: The court quashed the coroner’s refusal to accede to the application of the deceased’s father to resume an adjourned inquest into the death, at which . .
Cited – E and Others v The United Kingdom ECHR 26-Nov-2002
The four applicants had been abused by their stepfather, and sought investigation of the local authority for failing to protect them. They had been compensated by the Criminal Injuries Compensation Authority in part, but now sought a remedy from the . .
Cited – In Re J (Minors) (Care: Care Plan) FD 1994
The judge had found that the threshold criteria in section 31 had been met, but the authority changed the care plan immediately before the final hearing. The guardian now appealed a final order, having proposed an interim order.
Held: Once the . .
Cited – Osman v The United Kingdom ECHR 28-Oct-1998
Police’s Complete Immunity was Too Wide
(Grand Chamber) A male teacher developed an obsession with a male pupil. He changed his name by deed poll to the pupil’s surname. He was required to teach at another school. The pupil’s family’s property was subjected to numerous acts of vandalism, . .
Cited – Mastromatteo v Italy ECHR 24-Oct-2002
The deceased had been a bystander killed by a group of criminals, some of whom were on leave of absence from prison and one of whom had absconded from prison. A complaint was made by the applicant that there had been a breach of the positive duty to . .
Cited – Regina (A and others) (Widgery Soldiers) v Lord Saville of Newdigate and Others CA 19-Dec-2001
The court would apply common sense in deciding whether soldier witnesses should be obliged to attend in person at an enquiry in Londonderry, where they claimed their lives would be at risk. It was not appropriate to seek to define what would be . .
Cited – Re M (Threshold Criteria: Parental Concessions) CA 1999
In care proceedings the court is not constrained to take the shortest route to an uncontested disposal. Though, the court identified as a general principle ‘there should be no unnecessary litigation in the courts’. . .
Cited – Z And Others v The United Kingdom ECHR 10-May-2001
Four children complained that, for years before they were taken into care by the local authority, its social services department was well aware that they were living in filthy conditions and suffering ‘appalling’ neglect in the home of their . .
Cited – Re C and B (Care Order: Future Harm) CA 2001
Hale LJ said that ‘a comparatively small risk of really serious harm can justify action, while even the virtual certainty of slight harm might not’. . .
Cited – Powell v United Kingdom ECHR 4-May-2000
A ten-year old boy had died from Addison’s disease. No inquest took place, because the coroner decided that the boy had died of natural causes. The parents, who were also affected by the events, had accepted compensation from the local health . .

Cited by:

Cited – Scholes, Regina (on the Application of) v Secretary of State for the Home Department Admn 16-Jan-2006
The deceased had committed suicide whilst in a Young Offenders Institute. The coroner had called for a further enquiry into the way he had been sentenced. The Home Office refused a public enquiry saying that the coroner’s inquest had satisfied its . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 30 June 2022; Ref: scu.226743

Pearson v HM Coroner for Inner London North: Admn 9 Mar 2005

Relatives of the deceased said that the inquest carried out by the coroner was inadequate in Jamieson terms and had not satisfied the human rights issues. Maurice Kay LJ rejected the argument saying: ‘One does not reach the stage of resort to section 3 as a tool for interpretation unless and until it is established that the Human Rights Act applies. In Middleton and Sacker it was simply assumed, without demur, that it applied on a retrospective basis but with the point expressly left open. However, the point was very clearly decided in McKerr. It comes to this. When article 2 provides that ‘everyone’s right to life shall be protected by law’, it embraces both a positive obligation on the state to protect everyone’s life and a procedural requirement that there should be some form of effective official investigation when an individual has been killed. The present case is concerned with that procedural obligation. It is not the primary obligation imposed by article 2 but, in the words of Lord Nicholls, ‘a consequential obligation’. . The logic of McKerr is inexorable. If the positive obligation did not arise in domestic law prior to 2 October 2000, the consequential, secondary, ancillary or adjectival obligation cannot now give rise to a domestic obligation because it is consequential upon and secondary, ancillary and adjectival to the substantive obligation to protect life. I am driven to the conclusion that if the Appellate Committee in Middleton and Sacker had been required to address this question, it would have yielded to the same inexorable logic.’

Judges:

Maurice Kay LJ, Moses J

Citations:

[2005] EWHC 833 (Admin)

Links:

Bailii

Statutes:

Coroners Act 1988 13, Human Rights Act 1998 3

Cited by:

Cited – Hurst, Regina (on the Application of) v Commissioner of Police of the Metropolis v London Northern District Coroner HL 28-Mar-2007
The claimant’s son had been stabbed to death. She challenged the refusal of the coroner to continue with the inquest with a view to examining the responsibility of any of the police in having failed to protect him.
Held: The question amounted . .
Lists of cited by and citing cases may be incomplete.

Coroners, Human Rights

Updated: 30 June 2022; Ref: scu.224845

Parkin v HM Coroner for North Lincolnshire and Grimsby District: Admn 23 Mar 2005

The family appealed against an open verdict. Her son was found hanged at school. The coroner felt unable to be sure that he had committed suicide. He had been looking forward to a new job as a theatre technician.
Held: There was evidence available now which had not been available at the inquest which undermined the understanding of the boy’s expectations, and might in fact be excluded from the drama club for drinking. It was also now doubted whether the rope by which he had been found hanging could have sufficed to cause his death by hanging. There was sufficient cause to find an: ‘insufficiency of inquiry, the discovery of new facts or evidence or otherwise’ and a new inquest was required.

Judges:

Kay LJ, Holland J

Citations:

[2005] EWHC 660 (Admin)

Links:

Bailii

Statutes:

Coroners Act 1988 18

Jurisdiction:

England and Wales

Citing:

Cited – In re Rapier (Deceased) QBD 1988
A young prisoner had been found dead in his cell hanging. A report suggested that he may have been sniffing solvents. The coroner himself initiated proceedings both under the Coroners’ Act and for judicial review to quash the inquisition over which . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Sacker, Regina (on the Application of) v Coroner for the County of West Yorkshire HL 11-Mar-2004
The deceased committed suicide in prison. Her family sought to have added to the verdict the words ‘contributed by neglect’ and complained that the inquest had not provided a full and proper investigation of the death.
Held: The Act needed to . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson QBD 12-Jul-1993
A prisoner had hanged himself after being left unsupervised in a single cell. He was a known suicide risk, but the Coroner directed the jury not to return a verdict which included any reference to lack of care.
Held: A coroner was free not to . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 29 June 2022; Ref: scu.224528

Police Service of Northern Ireland v McCaughey and Another: CANI 14 Jan 2005

Judges:

Kerr LCJ, Campbell LJ and Weir J

Citations:

[2005] NICA 1

Links:

Bailii

Statutes:

Coroner’s Act (Northern Ireland) 1959, European Convention on Human Rights

Jurisdiction:

Northern Ireland

Citing:

See Also – McCaughey and Another, Re Application for Judicial Review QBNI 20-Jan-2004
Application by the fathers of Martin McCaughey and Desmond Grew, who were killed by soldiers on 9 October 1990, for Judicial Review of the decisions of the Chief Constable and the Coroner concerning the disclosure of documents for the purposes of . .

Cited by:

See Also – Jordan v Lord Chancellor and Another (Northern Ireland) HL 28-Mar-2007
In each case a death had occurred many years earlier where the deceased had apparently died at the hands of the armed forces. The relatives now challenged the range of verdicts which could be left to a coroner’s jury.
Lord Bingham said: ‘The . .
See Also – McCaughey and Quinn, Re Judicial Review CANI 26-Mar-2010
The claimants challenged the mode of inquest sought to be carried out. They had been refused an undertaking that the inquest would comply with obligations under article 2.
Held: The appeal failed. McKerr remained binding on the court, even if . .
See Also – McCaughey and Another, Re Application forJudicial Review SC 18-May-2011
The claimants sought a fuller inquest into deaths at the hands of the British Army in 1990 in Northern Ireland. On opening the inquest, the coroner had declined to undertake to hold a hearing compliant with article 2, and it had not made progress. . .
Lists of cited by and citing cases may be incomplete.

Police, Human Rights, Coroners

Updated: 29 June 2022; Ref: scu.224131

Goodson v HM Coroner for Bedfordshire and Luton: Admn 17 Dec 2004

A patient had died in hospital following an operation. The NHS Trust submitted that ‘There is a real distinction between cases of medical negligence, which were specifically addressed as a discrete area in Calvelli, and cases of intentional killing or failure to protect someone in custody.’
Held: ‘Calvelli is both the most recent decision and also a decision of the Grand Chamber; and the judgment in that case analyses the matter solely in terms of the positive obligation to set up an effective judicial system, without reference to the separate procedural obligation to investigate . . Whether the matter is analysed in terms of the positive obligation to set up an effective judicial system or in terms of the procedural obligation to investigate may not ultimately be of great significance. Although certain minimum criteria are laid down, the actual nature of an investigation required under article 2 varies according to context; and the Strasbourg cases on deaths resulting from alleged medical negligence show that, if the procedural obligation does apply, the range of remedies available under the judicial system (criminal, civil and possibly disciplinary) can be sufficient to discharge it.’

Judges:

Richards J

Citations:

[2004] EWHC 2931 (Admin), [2005] 2 All ER 791, [2006] 1 WLR 432, [2005] Lloyds Rep Med 202, (2005) 84 BMLR 72, [2005] Lloyd’s Rep Med 202

Links:

Bailii

Citing:

Cited – Calvelli and Ciglio v Italy ECHR 17-Jan-2002
The applicants’ baby had died shortly after birth in 1987. They complained about the medical care. The complaint was not investigated speedily by the authority, resulting in a criminal complaint becoming time barred after a conviction in 1994 was . .

Cited by:

Cited – D, Regina (on the Application of) v Secretary of State for the Home Department Admn 28-Apr-2005
D was undergoing trial for offences and was held in prison. He self-harmed repeatedly, and was recorded to require extra vigilance. He attempted to hang himself. Prison staff saved his life, but he was left paraplegic, and was then detained under . .
Cited – D, Regina (on the Application of) v Secretary of State for the Home Department Admn 28-Apr-2005
D was undergoing trial for offences and was held in prison. He self-harmed repeatedly, and was recorded to require extra vigilance. He attempted to hang himself. Prison staff saved his life, but he was left paraplegic, and was then detained under . .
Cited – Takoushis, Regina (on the Application of) v HM Coroner for Inner North London and others CA 30-Nov-2005
Relatives sought judicial review of the coroner’s decision not to allow a jury, and against allowance of an expert witness. The deceased had been a mental patient but had been arrested with a view to being hospitalised. He was taken first to the . .
See Also – Goodson v HM Coroner for Bedfordshire and Luton and Another (No 2) CA 12-Oct-2005
The applicant intended to appeal refusal of her challenge to the verdict of the coroner. For the first time at appeal she sought a protective costs order.
Held: The Corner House case established that a request for a protective costs order . .
Cited – Savage v South Essex Partnership NHS Foundation Trust (MIND intervening) HL 10-Dec-2008
The deceased had committed suicide on escaping from a mental hospital. The Trust appealed against a refusal to strike out the claim that that they had been negligent in having inadequate security.
Held: The Trust’s appeal failed. The fact that . .
Cited – Tyrrell v HM Senior Coroner County Durham and Darlington and Another Admn 26-Jul-2016
The court was aked what article 2 of the European Convention on Human Rights requires of a coroner when a serving prisoner dies of natural causes.
Held: The reuest for judicial review failed. Mr Tyrrell’s death was, from the outset, one which . .
Lists of cited by and citing cases may be incomplete.

Coroners, Human Rights

Updated: 28 June 2022; Ref: scu.221030

Regina (Anderson and Others) v HM Coroner for Inner North Greater London: QBD 26 Nov 2004

The deceased suffered depressive mental illness, and was detained outside on a cold night naked and in a cannabis induced delirium. Because of his size, additional officers were called upon to assist restraining him. He was taken to hospital, but died of a cardiac arrest whilst being restrained pending the arrival of a doctor. The family believed excessive force had been used. The coroner’s jury returned a verdict of unlawful killing. The officers asked the court to quash the verdict.
Held: The coroner would have been justified in not leaving the verdict of unlawful killing to the jury: ‘The evidence to support it was very tenuous and the absence of any criticism of the police was a telling point. But it was more likely that being held face down would have produced hypoxia and so it was open to the jury to find causation proved. It was vitally important that they should have received a careful direction so that they knew that it was only if the holding face down had contributed substantially to hypoxia and that hypoxia had contributed substantially to death that a verdict of unlawful killing could be found. They received no such direction. Thus I am just persuaded that the coroner did not err in law in leaving unlawful killing to the jury. Equally, he would not have erred if he had declined to leave it. ‘ However: ‘I have no doubt that a verdict of unlawful killing was not and would not be a just verdict.’ The verdict was quashed.

Judges:

Mr Justice Collins

Citations:

[2004] EWHC 2729 (Admin)

Links:

Bailii

Statutes:

Mental Health Act 1983 136

Jurisdiction:

England and Wales

Citing:

Cited – Palmer v The Queen PC 23-Nov-1970
It is a defence in criminal law to a charge of assault if the defendant had an honest belief that he was going to be attacked and reacted with proportionate force: ‘If there has been an attack so that defence is reasonably necessary, it should be . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Regina v HM Coroner for Inner London South District, ex parte Douglas-Williams CA 29-Jan-1998
The deceased died in custody. The jury returned a verdict of accidental death. It was suggested that the coroner’s direction as to unlawful killing had been confusing, and that he was wrong not to leave open the possibility of a verdict of neglect. . .
Cited – Regina v Galbraith CCA 1981
Rejection of Submission of No Case to Answer
The defendant had faced a charge of affray. The court having rejected his submission of having no case to answer, he had made an exculpatory statement from the dock. He appealed against his conviction.
Held: Lord Lane LCJ said: ‘How then . .
Cited – Regina v HM Coroner for Inner London South District, ex parte Douglas-Williams CA 29-Jan-1998
The deceased died in custody. The jury returned a verdict of accidental death. It was suggested that the coroner’s direction as to unlawful killing had been confusing, and that he was wrong not to leave open the possibility of a verdict of neglect. . .
Lists of cited by and citing cases may be incomplete.

Coroners, Police

Updated: 27 June 2022; Ref: scu.220045

Bennett v Officers A and B and Commissioner of Police for the Metropolis: CA 2 Nov 2004

Police Officers had been involved in a shooting in which a man died. They were granted anonymity before the coroner’s court, on evidence suggesting they might be at risk. The family of the deceased appealed.
Held: The coroner misdirected herself in respect of the threshold of risk test by allowing for ‘a reasonable chance’ of a threat, but the misdirection was not such as to require this matter to be remitted to her for a further hearing.

Judges:

Lord Justice Mummery Mr Justice Maurice Kay

Citations:

[2004] EWCA Civ 1439, [2004] All ER 27

Links:

Bailii

Statutes:

European Convention on Human Rights 2

Jurisdiction:

England and Wales

Citing:

Cited – Regina v Secretary of State for Defence Ex Parte Smith; Regina v Same Ex Parte Grady Etc CA 6-Nov-1995
A ban on homosexuals serving in the armed forces was not irrational, and the challenge to the ban failed. The greater the policy content of a decision, and the more remote the subject matter of a decision from ordinary judicial experience, the more . .
Cited – A and Others, Regina (on the Application of) v Lord Saville of Newdigate and others CA 28-Jul-1999
Former soldiers who had been involved in the events in Londonderry in 1972, and were to be called to give evidence before a tribunal of inquiry, still had cause to fear from their names being given, and so were entitled to anonymity when giving such . .
Cited – Regina v Bedfordshire Coroner ex parte Local Sunday Newspapers Ltd 1999
The test of whether a coroner should grant anonimity to a witness involved a decision on whether or not there was objective evidence to show that the fears of the Respondent established a serious or real possibility of danger to life. Burton J . .
Cited – Amin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
Prisoner’s death – need for full public enquiry
The deceased had been a young Asian prisoner. He was placed in a cell overnight with a prisoner known to be racist, extremely violent and mentally unstable. He was killed. The family sought an inquiry into the death.
Held: There had been a . .
Cited – Scott v Scott HL 5-May-1913
Presumption in Favour of Open Proceedings
There had been an unauthorised dissemination by the petitioner to third parties of the official shorthand writer’s notes of a nullity suit which had been heard in camera. An application was made for a committal for contempt.
Held: The House . .
Cited – Regina v Governor of Pentonville Prison, Ex parte Fernandez: Fernandez v Government of Singapore HL 1971
Test for police protection need
The court considered the degree of risk to an individual which should give rise to a duty on the police to protect him under article 2.
Held: Lord Diplock said: ‘My Lords, bearing in mind the relative gravity of the consequences of the court’s . .

Cited by:

Cited – In re Officer L HL 31-Jul-2007
Police officers appealed against refusal of orders protecting their anonymity when called to appear before the Robert Hamill Inquiry.
Held: ‘The tribunal accordingly approached the matter properly under article 2 in seeking to ascertain . .
Cited – Associated Newspapers Ltd, Regina (on The Application of) v Rt Hon Lord Justice Leveson Admn 20-Jan-2012
The defendant was conducting a public enquiry into the culture, ethics and practices of national newspapers. The claimant and others objected to the admission of anonymous evidence from journalists afraid of career blight. The claimants complained . .
Lists of cited by and citing cases may be incomplete.

Police, Coroners, Human Rights

Updated: 27 June 2022; Ref: scu.219166

Longfield Care Homes Ltd, Regina (on the Application Of) v HM Coroner for Blackburn and others: Admn 14 Oct 2004

An elderly lady had died after falling from an open window at her care home. Although she suffered moderately severe injuries from the fall, they were not serious enough of themselves to cause her death which resulted from pre-existing pneumonia, but they did accelerate the process.
Held: A simple verdict of ‘accidental death to which neglect contributed’ was inadequate and that a narrative verdict explaining the circumstances of the death was required.

Judges:

Mitting J

Citations:

[2004] EWHC 2467 (Admin)

Links:

Bailii

Jurisdiction:

England and Wales

Citing:

Applied – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.

Cited by:

Cited – Goodson v HM Coroner for Bedfordshire and Luton and Another (No 2) CA 12-Oct-2005
The applicant intended to appeal refusal of her challenge to the verdict of the coroner. For the first time at appeal she sought a protective costs order.
Held: The Corner House case established that a request for a protective costs order . .
Cited – Ministry of Defence v Her Majesty’s Coroner for Wiltshire and Swindon and others Admn 13-Feb-2006
The ministry appealed against the verdict that the deceased had been unlawfully killed. He had ingested sarin during an experiment on him at Porton Down in 1953. The court was asked itself to amend the verdict.
Held: There had been a full . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 13 June 2022; Ref: scu.219267

Hemsworth, Re an Application for Judicial Review: QBNI 26 Apr 2004

Application for Judicial Review of a decision of the Legal Aid Department on an application for legal aid under the green form scheme in connection with preparatory legal work for the Inquest into the death of the applicant’s husband. This application involves two broad attacks, the first being to the particular decision and the second being to the compatibility of the green form scheme with the procedural requirements of Article 2 of the European Convention.

Judges:

Weatherup J

Citations:

[2004] NIQB 26

Links:

Bailii

Northern Ireland, Coroners, Human Rights, Legal Aid

Updated: 10 June 2022; Ref: scu.196127

Sacker, Regina (on the Application of) v Coroner for the County of West Yorkshire: HL 11 Mar 2004

The deceased committed suicide in prison. Her family sought to have added to the verdict the words ‘contributed by neglect’ and complained that the inquest had not provided a full and proper investigation of the death.
Held: The Act needed to be read in its broader meaning to be compliant with the 1998 Act. ‘The word ‘how’ in section 11(5)(b)(ii) of the 1988 Act and rule 36(1)(b) of the 1984 Rules is open to the interpretation that it means not simply ‘by what means’ but rather ‘by what means and in what circumstances . . it should now be given the broader meaning.’ A fresh inquest was appropriate.

Judges:

Lord Bingham of Cornhill, Lord Hope of Craighead, Lord Walker of Gestingthorpe, Baroness Hale of Richmond and Lord Carswell

Citations:

Times 12-Mar-2004, [2004] UKHL 11, Gazette 22-Apr-2004, [2004] Lloyds Rep Med 281, [2004] UKHRR 521, [2004] 2 All ER 487, (2004) 79 BMLR 40, [2004] 1 WLR 796

Links:

Bailii, House of Lords

Statutes:

Coroners Act 1988 8(1)(c) 11(5)(b)(ii), Human Rights Act 1998 3

Jurisdiction:

England and Wales

Citing:

Appeal from – Sacker v HM Coroner for the County of West Yorkshire CA 27-Feb-2003
The court expressed scepticism about the suitability of a coroner’s inquest, in its present form, as a vehicle for carrying out a state’s obligations under Article 2. Those considerations may accentuate the need for an overdue improvement in the . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Amin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
Prisoner’s death – need for full public enquiry
The deceased had been a young Asian prisoner. He was placed in a cell overnight with a prisoner known to be racist, extremely violent and mentally unstable. He was killed. The family sought an inquiry into the death.
Held: There had been a . .

Cited by:

Appealed to – Sacker v HM Coroner for the County of West Yorkshire CA 27-Feb-2003
The court expressed scepticism about the suitability of a coroner’s inquest, in its present form, as a vehicle for carrying out a state’s obligations under Article 2. Those considerations may accentuate the need for an overdue improvement in the . .
Cited – Parkin v HM Coroner for North Lincolnshire and Grimsby District Admn 23-Mar-2005
The family appealed against an open verdict. Her son was found hanged at school. The coroner felt unable to be sure that he had committed suicide. He had been looking forward to a new job as a theatre technician.
Held: There was evidence . .
Cited – JL, Regina (on the Application of) v Secretary of State for Justice; Regina (L (A Patient)) v Secretary of State for the Home Department HL 26-Nov-2008
The prisoner was left with serious injury after attempting suicide in prison. He said that there was a human rights duty to hold an investigation into the circumstances leading up to this.
Held: There existed a similar duty to hold an enhanced . .
Cited – Savage v South Essex Partnership NHS Foundation Trust (MIND intervening) HL 10-Dec-2008
The deceased had committed suicide on escaping from a mental hospital. The Trust appealed against a refusal to strike out the claim that that they had been negligent in having inadequate security.
Held: The Trust’s appeal failed. The fact that . .
Cited – Lewis, Regina (on The Application of) v HM Coroner for The Mid and North Division of The County of Shropshire and Another CA 21-Dec-2009
The claimant’s son was found hanging in his prison cell. He appealed refusal of a judicial review of the coroner’s decision not to put to the jury a question as to certain possible causative matters. The youth was seen hanging, but the guard called . .
Cited – Smith, Regina (on The Application of) v Secretary of State for Defence and Oxfordshire Assistant Deputy Coroner (Equality and Human Rights Commission intervening) SC 30-Jun-2010
The deceased soldier died of heat exhaustion whilst on active service in Iraq. It was said that he was owed a duty under human rights laws, and that any coroner’s inquest should be a fuller one to satisfy the state’s duty under Article 2.
Lists of cited by and citing cases may be incomplete.

Coroners, Prisons, Human Rights

Updated: 10 June 2022; Ref: scu.194439

McCaughey and Another, Re Application for Judicial Review: QBNI 20 Jan 2004

Application by the fathers of Martin McCaughey and Desmond Grew, who were killed by soldiers on 9 October 1990, for Judicial Review of the decisions of the Chief Constable and the Coroner concerning the disclosure of documents for the purposes of the Inquests into the deaths.

Judges:

Weatherup J

Citations:

[2004] NIQB 2

Links:

Bailii

Jurisdiction:

Northern Ireland

Cited by:

Cited – In re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
Cited – Jordan v Lord Chancellor and Another (Northern Ireland) HL 28-Mar-2007
In each case a death had occurred many years earlier where the deceased had apparently died at the hands of the armed forces. The relatives now challenged the range of verdicts which could be left to a coroner’s jury.
Lord Bingham said: ‘The . .
See Also – Police Service of Northern Ireland v McCaughey and Another CANI 14-Jan-2005
. .
See Also – McCaughey and Quinn, Re Judicial Review CANI 26-Mar-2010
The claimants challenged the mode of inquest sought to be carried out. They had been refused an undertaking that the inquest would comply with obligations under article 2.
Held: The appeal failed. McKerr remained binding on the court, even if . .
See Also – McCaughey and Another, Re Application forJudicial Review SC 18-May-2011
The claimants sought a fuller inquest into deaths at the hands of the British Army in 1990 in Northern Ireland. On opening the inquest, the coroner had declined to undertake to hold a hearing compliant with article 2, and it had not made progress. . .
Lists of cited by and citing cases may be incomplete.

Coroners, Human Rights, Litigation Practice

Updated: 09 June 2022; Ref: scu.192356

Regina on the Application Of Christine Davies v HM Deputy Coroner for Birmingham: CA 2 Dec 2003

Judges:

Lord Justice Brooke Sir Martin Nourse Lord Justice Longmore

Citations:

[2003] EWCA Civ 1739

Links:

Bailii

Jurisdiction:

England and Wales

Citing:

Appeal from – Davies, Regina (on the Application of) v HM Deputy Coroner for Birmingham and Another Admn 11-Feb-2003
. .
Costs reserved to – Regina on the Application of Davies (No 2) v HM Deputy Coroner for Birmingham CA 27-Feb-2004
The claimant appealed against a costs order. She had previously appealed against an order of the High Court on her application for judicial review of the inquest held by the respondent.
Held: The coroner, and others in a similar position . .

Cited by:

Appealed to – Davies, Regina (on the Application of) v HM Deputy Coroner for Birmingham and Another Admn 11-Feb-2003
. .
Reserved from – Regina on the Application of Davies (No 2) v HM Deputy Coroner for Birmingham CA 27-Feb-2004
The claimant appealed against a costs order. She had previously appealed against an order of the High Court on her application for judicial review of the inquest held by the respondent.
Held: The coroner, and others in a similar position . .
Lists of cited by and citing cases may be incomplete.

Coroners, Prisons

Updated: 08 June 2022; Ref: scu.188394

Regina on the Application of Mullholland v HM Coroner for St Pancras: QBD 7 Nov 2003

The applicant sought to re-open a coroner’s inquest. The deceased had been drunk, slipped banged his head and fallen to the ground. Police and ambulance were called. The ambulance worker was not told he had been unconscious, and he was taken to the police station. At the police station, he became seriously ill. He died later at hospital.
Held: Those atending were not told of the period of unconsciousness, and the deceased had refused to go to hospital. Even though there was now evidence which suggested he might have lived, the decision not to go to hospital was unlikely to be challenged and a different verdict had not been shown to be likely.

Judges:

Lord Justice Kennedy Mr Justice Royce

Citations:

[2003] EWHC 2612 (Admin)

Links:

Bailii

Jurisdiction:

England and Wales

Citing:

Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – O’Reilly v Coventry Coroner QBD 3-Apr-1996
The inquest was said to have been flawed because relevant material was withheld from the jury, factual issues were not addressed, and the Coroner had refused to leave open the possibility of a verdict of lack of care or neglect. The deceased had . .
Cited – In the Matter of Captain Christopher John Kelly Admn 14-Jun-1996
The deceased was killed by ‘friendly fire’ during a night exercise in Kenya. A verdict of accidental death was returned, and a fresh inquest was sought particularly in the light of a statement from a fellow officer.
Held: The emergence of . .
Cited – Regina v HM Coroner for Inner London South District, ex parte Douglas-Williams CA 29-Jan-1998
The deceased died in custody. The jury returned a verdict of accidental death. It was suggested that the coroner’s direction as to unlawful killing had been confusing, and that he was wrong not to leave open the possibility of a verdict of neglect. . .
Cited – Regina v HM Coroner ex parte Chief Constable of South Wales Admn 1999
The deceased was found in the street having taken drink and drugs. At a police station he was seen by a doctor who found him fit to be detained, but he died next morning. A jury recorded a verdict of ‘drug abuse contributed to by neglect’. It was . .
Cited – Nicholls v Coroner for City of Liverpool Admn 8-Nov-2001
As the deceased was arrested he swallowed something. He was examined by a doctor and denied that he had swallowed drugs, but his condition deteriorated and he died at hospital. The coroner refused to admit the evidence of a professor who was highly . .
Cited – Regina (Amin) v Secretary of State for the Home Department QBD 5-Oct-2001
An Asian youth was placed in a cell with another who was well known to be violent and racist. He was bludgeoned to death. The family sought a public investigation into how he came to be placed in such a position. An investigation had been refused by . .
See Also – Mulholland, Regina (on the Application of) v HM Coroner for St Pancras Admn 16-Jan-2003
. .

Cited by:

See also – Mulholland, Regina (on the Application of) v HM Coroner for St Pancras Admn 16-Jan-2003
. .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 08 June 2022; Ref: scu.187728

Menson v United Kingdom: ECHR 6 May 2003

There had been a racist attack. The victim was set on fire and killed in the street by assailants. His relatives sought compensation. However the assailants were not agents of the state and they were duly prosecuted, convicted and sentenced. No blame attached to state authorities for the killing and no breach of the state’s investigative duty was found.
Held: While certain familiar principles were rehearsed, the complaint was held to be manifestly ill-founded.
‘The Court observes that the applicants have not laid any blame on the authorities of the respondent State for the actual death of Michael Menson; nor has it been suggested that the authorities knew or ought to have known that Michael Menson was at risk of physical violence at the hands of third parties and failed to take appropriate measures to safeguard him against that risk. The applicants’ case is therefore to be distinguished from cases involving the alleged use of lethal force either by agents of the State or by private parties with their collusion (see, for example, McCann v United Kingdom (1995) [21 EHRR 97]; Jordan v United Kingdom (2001) [37 EHRR 52]; Shanaghan v United Kingdom, (Application No 37715/97, BAILII: [2001] ECHR 330), judgment of 4 May 2001, ECHR 2001-III (extracts), or in which the factual circumstances imposed an obligation on the authorities to protect an individual’s life, for example where they have assumed responsibility for his welfare (see, for example, Edwards v United Kingdom (2002) [35 EHRR 487]), or where they knew or ought to have known that his life was at risk (see, for example, Osman v United Kingdom (1998) 29 EHRR 245 . . However, the absence of any direct state responsibility for the death of Michael Menson does not exclude the applicability of article 2. It recalls that by requiring a State to take appropriate steps to safeguard the lives of those within its jurisdiction (see LCB v United Kingdom (1998) 27 EHRR 212] para 36), article 2 para 1 imposes a duty on that state to secure the right to life by putting in place effective criminal law provisions to deter the commission of offences against the person, backed up by law enforcement machinery for the prevention, suppression and punishment of breaches of such provisions.
With reference to the facts of the instant case, the Court considers that this obligation requires by implication that there should be some form of effective official investigation when there is reason to believe that an individual has sustained life-threatening injuries in suspicious circumstances. The investigation must be capable of establishing the cause of the injuries and the identification of those responsible with a view to their punishment. Where death results, as in Michael Menson’s case, the investigation assumes even greater importance, having regard to the fact that the essential purpose of such an investigation is to secure the effective implementation of the domestic laws which protect the right to life.’

Citations:

47916/99, [1998] ECHR 107, (2003) 37 EHRR CD 220, [2003] Inquest LR 146, [2003] Po LR 155

Links:

Bailii

Statutes:

European Convention on Human Rights 2

Jurisdiction:

Human Rights

Cited by:

Cited – Amin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
Prisoner’s death – need for full public enquiry
The deceased had been a young Asian prisoner. He was placed in a cell overnight with a prisoner known to be racist, extremely violent and mentally unstable. He was killed. The family sought an inquiry into the death.
Held: There had been a . .
Cited – D, Regina (on the Application of) v Secretary of State for the Home Department (Inquest Intervening) CA 28-Feb-2006
The respondent appealed from orders made as to the conduct of an investigation into an attempted suicide in prison. The judge had severely criticised the appellant’s treatment of the case.
Held: The appeal failed. The court recited the . .
Cited – Reynolds, Regina (on the Application of) v Independent Police Complaints Commission and Another CA 22-Oct-2008
The court was asked to consider whether the IPCC could investigate the circumstances leading to the arrest of a suspect who fell into a coma after being arrested for being drunk. The IPCC appealed, saying that it did not have jurisdiction to . .
Cited – Smith, Regina (on The Application of) v Secretary of State for Defence and Oxfordshire Assistant Deputy Coroner (Equality and Human Rights Commission intervening) SC 30-Jun-2010
The deceased soldier died of heat exhaustion whilst on active service in Iraq. It was said that he was owed a duty under human rights laws, and that any coroner’s inquest should be a fuller one to satisfy the state’s duty under Article 2.
Cited – Secic v Croatia ECHR 31-May-2007
The applicant had been attacked and beaten by skinheads shouting racial abuse. He complained that as a Roma, the police had failed through race discrimination properly to investigate his complaint.
Held: The court repeated the statement that . .
Cited – Commissioner of Police of The Metropolis v DSD and Another SC 21-Feb-2018
Two claimants had each been sexually assaulted by a later notorious, multiple rapist. Each had made complaints to police about their assaults but said that no effective steps had been taken to investigate the serious complaints.
Held: The . .
Lists of cited by and citing cases may be incomplete.

Human Rights, Coroners

Updated: 08 June 2022; Ref: scu.186853

Khan, Regina (on the Application of) v Secretary of State for Health: CA 10 Oct 2003

The claimant’s child had died as a result of negligence in hospital. The parents had been told the result of police investigation and decision not to prosecute, and the hospital’s own investigation, but had not been sufficiently involved. There remained unresolved suspicions of negligence having been covered up. They had been refused legal aid to be represented at the inquest.
Held: ‘Where agents of a state bear potential responsibility for the loss of a human life, the state should provide a procedural mechanism whereby the cause of death may be investigated, and responsibility for the death ascertained, through an investigation held in public which must be both judicial and effective; The Convention is not prescriptive about the manner in which this investigation should take place, but the more serious the events that call for inquiry, the more intensive should be the process of public scrutiny. In such cases the families of the deceased should be involved in the procedure to the extent that is necessary to safeguard their interests.’
The inquest might not be sufficiently wide ranging to satisfy the right, and the respondent should take an opportunity to reconsider his decision not to provide assistance: ‘The procedural obligation introduced by article 2 has three interlocking aims: to minimise the risk of future like deaths; to give the beginnings of justice to the bereaved; and to assuage the anxieties of the public.’
‘the function of an inquest is inquisitorial, and in the overwhelming majority of cases the coroner can conduct an effective judicial investigation himself without there being any need for the family of the deceased to be represented’

Judges:

Brooke VP, Waller, Clarke LJJ

Citations:

[2004] 1 WLR 971, [2003] EWCA Civ 1129, Times 15-Oct-2003, Gazette 20-Nov-2003, [2003] Inquest LR 70, [2003] 3 FCR 341, (2004) 76 BMLR 118, [2003] ACD 89, (2004) 7 CCL Rep 361, [2003] 4 All ER 1239, [2004] Lloyd’s Rep Med 159

Links:

Bailii

Statutes:

European Convention on Human Rights 2

Jurisdiction:

England and Wales

Citing:

Cited – Powell v United Kingdom ECHR 4-May-2000
A ten-year old boy had died from Addison’s disease. No inquest took place, because the coroner decided that the boy had died of natural causes. The parents, who were also affected by the events, had accepted compensation from the local health . .
Cited – Regina (Amin) v Secretary of State for the Home Department; Regina (Middleton) v Coroner for West Somersetshire CA 27-Mar-2002
A prisoner had been killed in his cell by a cell-mate known to be unstable and racist. His family sought to be involved in the inquiry into the death within the prison system. A second prisoner hanged himself in his cell. His family alleged that he . .
Cited – Osman v The United Kingdom ECHR 28-Oct-1998
Police’s Complete Immunity was Too Wide
(Grand Chamber) A male teacher developed an obsession with a male pupil. He changed his name by deed poll to the pupil’s surname. He was required to teach at another school. The pupil’s family’s property was subjected to numerous acts of vandalism, . .
Cited – Sieminska v Poland ECHR 29-Mar-2001
The applicant’s husband died in hospital, but she later complained that the ambulance had not been equipped with the necessary resuscitation devices. Under Polish law she had a right to appeal against decisions of the prosecuting authorities not to . .
Cited – Calvelli and Ciglio v Italy ECHR 17-Jan-2002
The applicants’ baby had died shortly after birth in 1987. They complained about the medical care. The complaint was not investigated speedily by the authority, resulting in a criminal complaint becoming time barred after a conviction in 1994 was . .
Cited – Edwards v The United Kingdom ECHR 14-Mar-2002
The deceased, a young man of mixed race, had been placed in a cell with another prisoner who was known to be violent, racist, and mentally unstable. The staff knew that the panic button was defective. The deceased was murdered by his cell-mate. His . .
Cited – Jordan v United Kingdom; McKerr v United Kingdom; similar ECHR 4-May-2001
Proper Investigation of Deaths with Army or Police
Claims were made as regards deaths of alleged terrorists in clashes with the UK armed forces and police. In some cases the investigations necessary to justify the taking of life had been inadequate. Statements made to the inquiry as to the . .
Cited – Oneryildiz v Turkey ECHR 30-Nov-2004
(Grand Chamber) The applicant had lived with his family in a slum bordering on a municipal household refuse tip. A methane explosion at the tip resulted in a landslide which engulfed the applicant’s house killing his close relatives.
Held: The . .
Cited – Mastromatteo v Italy ECHR 24-Oct-2002
The deceased had been a bystander killed by a group of criminals, some of whom were on leave of absence from prison and one of whom had absconded from prison. A complaint was made by the applicant that there had been a breach of the positive duty to . .
Cited – Hurst v Coroner Northern District of London Admn 4-Jul-2003
The deceased was killed by Mr Reid, a neighbour, who was convicted of his manslaughter.
Held: The court quashed the coroner’s refusal to accede to the application of the deceased’s father to resume an adjourned inquest into the death, at which . .
Cited – Sacker v HM Coroner for the County of West Yorkshire CA 27-Feb-2003
The court expressed scepticism about the suitability of a coroner’s inquest, in its present form, as a vehicle for carrying out a state’s obligations under Article 2. Those considerations may accentuate the need for an overdue improvement in the . .
Cited – Regina v Secretary of State for Health, Ex Parte Wagstaff etc QBD 31-Aug-2000
The Secretary of State announced a public enquiry into the Shipman case. He did not say whether it would be a public enquiry. The bereaved families and media wanted it to be public, and contended that it had been invalidly constituted, that an . .
Cited – Credit Suisse and Another v Waltham Forest London Borough Council CA 20-May-1996
Parliament had made detailed provision in a number of Acts for the discharge of the housing duties by local authorities. These detailed provisions did not contain a power to give a guarantee in connection with a bank loan to a company which the . .
Appeal from – Khan, Regina (on the Application Of) v Secretary of State for Health Admn 17-Jun-2003
. .

Cited by:

Cited – In re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
Cited – Plymouth City Council v HM Coroner for the County of Devon and Another Admn 27-May-2005
The local authority in whose care the deceased child had been held challenged a decision by the coroner not to limit his inquiry to the last few days of the child’s life. The coroner had decided that he had an obligation to conduct a wider enquiry . .
Cited – Letts, Regina (on The Application of) v The Lord Chancellor and Another Admn 20-Feb-2015
Application for judicial review concerning the criteria applied by the Legal Aid Agency to determine whether relatives of a deceased should be granted legal aid for representation at an inquest into a death which has arisen in circumstances which . .
Lists of cited by and citing cases may be incomplete.

Human Rights, Legal Aid, Coroners

Updated: 08 June 2022; Ref: scu.186692

Mulholland, Regina (on the Application of) v HM Coroner for St Pancras: Admn 16 Jan 2003

Citations:

[2003] EWHC 96 (Admin)

Links:

Bailii

Jurisdiction:

England and Wales

Citing:

See also – Regina on the Application of Mullholland v HM Coroner for St Pancras QBD 7-Nov-2003
The applicant sought to re-open a coroner’s inquest. The deceased had been drunk, slipped banged his head and fallen to the ground. Police and ambulance were called. The ambulance worker was not told he had been unconscious, and he was taken to the . .

Cited by:

See Also – Regina on the Application of Mullholland v HM Coroner for St Pancras QBD 7-Nov-2003
The applicant sought to re-open a coroner’s inquest. The deceased had been drunk, slipped banged his head and fallen to the ground. Police and ambulance were called. The ambulance worker was not told he had been unconscious, and he was taken to the . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 07 June 2022; Ref: scu.184628

Re Jordan: QBNI 6 Jan 2003

Citations:

[2003] NIQB 1

Links:

Bailii

Jurisdiction:

Northern Ireland

Citing:

See Also – Jordan, Re Application for Judicial Review (29) CANI 10-Sep-2004
. .
See Also – Jordan, Re Application for Judicial Review (30) CANI 10-Sep-2004
. .
See Also – Jordan, Re Application for Judicial Review QBNI 4-Sep-2001
An application was made for the production of documents by the police to support representations to be made on behalf of the family of the deceased to the coroner. The police requested but were refused undertakings as to their use. . .
Cited – Jordan, Re an Application for Judicial Review QBNI 12-Jan-2004
. .
Cited – Jordan, Re Application for Judicial Review CANI 12-Dec-2003
Appeal from a decision dismissing an application by Hugh Jordan for judicial review of the ‘continuing decision’ of the Director of Public Prosecutions for Northern Ireland refusing to give reasons other than in the most general terms for his . .
Cited – Jordan, Re Application for Judicial Review CANI 12-Sep-2003
The deceased had been shot by a sergeant of the RUC. The party sought to challenge a decision against the grant of legal aid. . .
Cited – Jordan, Re Application for Judicial Review CANI 28-May-2002
Whether the appeal against the decision of Kerr J dismissing the appellant’s applications for judicial review should be adjourned pending final determination of the proceedings in the English cases of R (Middleton) v HM Coroner for the Western . .
Cited – Regina v Kansal (2) HL 29-Nov-2001
The prosecutor had lead and relied at trial on evidence obtained by compulsory questioning under the 1986 Act.
Held: In doing so the prosecutor was acting to give effect to section 433.
The decision in Lambert to disallow retrospective . .

Cited by:

Cited – Jordan, Re Application for Judicial Review (29) CANI 10-Sep-2004
. .
Cited – Jordan, Re Application for Judicial Review (30) CANI 10-Sep-2004
. .
Cited – Jordan, Re an Application for Judicial Review QBNI 12-Jan-2004
. .
See Also – Jordan, Re Application for Judicial Review CANI 12-Dec-2003
Appeal from a decision dismissing an application by Hugh Jordan for judicial review of the ‘continuing decision’ of the Director of Public Prosecutions for Northern Ireland refusing to give reasons other than in the most general terms for his . .
Cited – Jordan, Re Application for Judicial Review CANI 12-Sep-2003
The deceased had been shot by a sergeant of the RUC. The party sought to challenge a decision against the grant of legal aid. . .
See Also – Jordan, Re Application for Judicial Review CANI 28-May-2002
Whether the appeal against the decision of Kerr J dismissing the appellant’s applications for judicial review should be adjourned pending final determination of the proceedings in the English cases of R (Middleton) v HM Coroner for the Western . .
See Also – Jordan, Re Application for Judicial Review QBNI 4-Sep-2001
An application was made for the production of documents by the police to support representations to be made on behalf of the family of the deceased to the coroner. The police requested but were refused undertakings as to their use. . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 07 June 2022; Ref: scu.180279

Sacker v HM Coroner for the County of West Yorkshire: CA 27 Feb 2003

The court expressed scepticism about the suitability of a coroner’s inquest, in its present form, as a vehicle for carrying out a state’s obligations under Article 2. Those considerations may accentuate the need for an overdue improvement in the arrangements for inquests

Judges:

The Hon Mr Justice Latham Lord Justice Mummery Lord Justice Pill

Citations:

[2003] EWCA Civ 217, [2003] Lloyds Med LR 326

Links:

Bailii

Statutes:

European Convention on Human Rights 2

Jurisdiction:

England and Wales

Citing:

Appealed to – Sacker, Regina (on the Application of) v Coroner for the County of West Yorkshire HL 11-Mar-2004
The deceased committed suicide in prison. Her family sought to have added to the verdict the words ‘contributed by neglect’ and complained that the inquest had not provided a full and proper investigation of the death.
Held: The Act needed to . .

Cited by:

Cited – Khan, Regina (on the Application of) v Secretary of State for Health CA 10-Oct-2003
The claimant’s child had died as a result of negligence in hospital. The parents had been told the result of police investigation and decision not to prosecute, and the hospital’s own investigation, but had not been sufficiently involved. There . .
Appeal from – Sacker, Regina (on the Application of) v Coroner for the County of West Yorkshire HL 11-Mar-2004
The deceased committed suicide in prison. Her family sought to have added to the verdict the words ‘contributed by neglect’ and complained that the inquest had not provided a full and proper investigation of the death.
Held: The Act needed to . .
Cited – Gentle and Others, Regina (on the Application of) v the Prime Minister and others Admn 20-Dec-2005
The applicants sought leave to bring judicial review of the decisions which led to the invasion of Iraq. They were relatives of servicemen who had died there.
Held: The court’s only duty at this stage was to ask whether there was an arguable . .
Lists of cited by and citing cases may be incomplete.

Coroners, Human Rights

Updated: 07 June 2022; Ref: scu.179565

McShane v The United Kingdom: ECHR 28 May 2002

HER Judgment (Merits and just satisfaction) Violation of Art. 2; No violation of Art. 6-1; No violation of Art. 14; No violation of Art. 13; Failure to comply with obligations under Article 34
The deceased died during a riot in Northern Ireland. He was under a hoarding run over by an armoured vehicle. Six years later an inquest had still not been held, civil proceedings remained pending, and an investigation by the Royal Ulster Constabulary found no basis for action.
Held: The Convention required by implication that there should be some form of effective official investigation when individuals have been killed as a result of the use of force. The failure to hold a proper inquiry into the death, was an infringement of the right to life under the Convention. The police officers investigating the incident were not independent of the officers implicated in the incident. There was however, no evidence which would entitle a conclusion that any deaths caused by the security services involved the unlawful or excessive use of force by members of the security forces, save where convictions had followed. The police had also in this case improperly put pressure on the applicant’s legal representatives with regard to evidence to be put before the court.

Judges:

M Pellonpaa, President, and Judges Sir Nicolas Bratza, A. Pastor Ridruejo, J. Makarczyk, V. Straznicka, R. Maruste and S. Pavlovschi Section Registrar M. O’Boyle

Citations:

Times 03-Jun-2002, 43290/98, [2002] ECHR 465, [2002] ECHR 469, (2002) 35 EHRR 593

Links:

Worldlii, Bailii

Statutes:

European Convention on Human Rights 2 34

Jurisdiction:

Human Rights

Cited by:

Cited – Gentle, Regina (on the Application of) and Another v The Prime Minister and Another HL 9-Apr-2008
The appellants were mothers of two servicemen who had died whilst on active service in Iraq. They appealed refusal to grant a public inquiry. There had already been coroners inquests. They said that Article 2 had been infringed.
Held: The . .
Lists of cited by and citing cases may be incomplete.

Human Rights, Coroners

Updated: 06 June 2022; Ref: scu.172160

Regina (Amin) v Secretary of State for the Home Department; Regina (Middleton) v Coroner for West Somersetshire: CA 27 Mar 2002

A prisoner had been killed in his cell by a cell-mate known to be unstable and racist. His family sought to be involved in the inquiry into the death within the prison system. A second prisoner hanged himself in his cell. His family alleged that he should have been kept on suicide watch. The coroner had not left the issue of neglect to the jury, but the jury had passed a note to him to say they wished to find neglect by the Prison Service. The family asked the coroner to append the note to his verdict. He refused. In each case the family challenged the decision, and the Home Secretary now appealed the resulting decisions.
Held: Though no explicit duty to investigate a death existed, under Human Rights law such a duty had developed. The court had to consider how such a duty applied in individual cases. The Jordan requirements were not set in stone. The enquiry into the one death had been adequate. As to the coroner’s verdict, there was no existing power to make a free standing verdict of neglect. Did that infringe the family’s rights? It was more important to identify defects in the system than to make findings of individual neglect. The Coroners Rules must be read so as to fit Human Rights law, and rule 42 should be read so as only to prevent findings of individual neglect. Coroners’ proceedings should not become adversarial. The state may have an adjectival duty under ECHR Article 2 in a case which did not involve an allegation of an intentional killing.

Judges:

Lord Woolf, Lord Chief Justice, Lord Justice Laws and Lord Justice Dyson

Citations:

Times 18-Apr-2002, Gazette 10-May-2002, [2002] EWCA Civ 390, [2003] QB 581

Links:

Bailii

Statutes:

Coroners Rules 1984 (1984 No 552) 42, European Convention on Human Rights 2

Jurisdiction:

England and Wales

Citing:

Applied – Edwards v The United Kingdom ECHR 14-Mar-2002
The deceased, a young man of mixed race, had been placed in a cell with another prisoner who was known to be violent, racist, and mentally unstable. The staff knew that the panic button was defective. The deceased was murdered by his cell-mate. His . .
Cited – Stephen Jordan v The United Kingdom (1) ECHR 14-Mar-2000
A commanding officer had decided that a soldier should be held in custody pending trial. The soldier complained that since the same commanding officer would later be involved in the preparation of the case against him, that decision was tainted and . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Appealed to – Amin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
Prisoner’s death – need for full public enquiry
The deceased had been a young Asian prisoner. He was placed in a cell overnight with a prisoner known to be racist, extremely violent and mentally unstable. He was killed. The family sought an inquiry into the death.
Held: There had been a . .
Appeal from – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset Admn 14-Dec-2001
The deceased had committed suicide whilst in prison. It was argued that the prison should have recognised that he was a suicide risk, and acted accordingly. The coroner had requested a note from the jury as to the cause of death. The court . .
Appealed to – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.

Cited by:

Cited – Khan, Regina (on the Application of) v HM Coroner for West Hertfordshire and Another Admn 7-Mar-2002
The deceased died in police custody. The coroner refused to leave to the jury possible verdicts of unlawful killing, or death contributed to by neglect, or breach of his right to life. He adjourned the hearing to allow this challenge.
Held: . .
Cited – Khan, Regina (on the Application of) v Secretary of State for Health CA 10-Oct-2003
The claimant’s child had died as a result of negligence in hospital. The parents had been told the result of police investigation and decision not to prosecute, and the hospital’s own investigation, but had not been sufficiently involved. There . .
Appeal from – Amin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
Prisoner’s death – need for full public enquiry
The deceased had been a young Asian prisoner. He was placed in a cell overnight with a prisoner known to be racist, extremely violent and mentally unstable. He was killed. The family sought an inquiry into the death.
Held: There had been a . .
Appeal from – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Appeal from – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Lists of cited by and citing cases may be incomplete.

Coroners, Prisons, Human Rights

Updated: 06 June 2022; Ref: scu.170038

Khan, Regina (on the Application of) v HM Coroner for West Hertfordshire and Another: Admn 7 Mar 2002

The deceased died in police custody. The coroner refused to leave to the jury possible verdicts of unlawful killing, or death contributed to by neglect, or breach of his right to life. He adjourned the hearing to allow this challenge.
Held: Coroners should be cautious of such adjournments. The jury would now deliver any verdict after a four month delay. The deceased had been involved in a struggle in the station, and lost consciousness, but had not been put in the recovery position for some time. Neglect in coroners’ cases meant failing to take an opportunity to avoid a death. However there was no evidence to support any conclusion that a relationship of causation existed to support a verdict of neglect.

Judges:

Mr Justice Richards

Citations:

[2002] EWHC 302 (Admin)

Links:

Bailii

Statutes:

European Convention on Human Rights

Jurisdiction:

England and Wales

Citing:

Cited – Regina v Inner London South District Coroner Ex Parte Douglas-Williams CA 30-Jul-1998
A coroner had the right not to leave all possible verdicts to a jury, even including one possibly supported by the evidence, where the overwhelming evidence pointed one way, and possible confusion of jury might be caused by leaving all verdicts to . .
Cited – Regina v Galbraith CCA 1981
Rejection of Submission of No Case to Answer
The defendant had faced a charge of affray. The court having rejected his submission of having no case to answer, he had made an exculpatory statement from the dock. He appealed against his conviction.
Held: Lord Lane LCJ said: ‘How then . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – Regina (Amin) v Secretary of State for the Home Department; Regina (Middleton) v Coroner for West Somersetshire CA 27-Mar-2002
A prisoner had been killed in his cell by a cell-mate known to be unstable and racist. His family sought to be involved in the inquiry into the death within the prison system. A second prisoner hanged himself in his cell. His family alleged that he . .
Cited – Regina (on the Application of Jean Marshall) v Her Majesty’s Coroner for Coventry Admn 22-Oct-2001
The applicant sought judicial review of the verdict of the coroner’s jury that a death had been accidental. The deceased, a schizophrenic died of an overdose of crack cocaine, whilst in police custody. His family sought a verdict of accidental death . .
Cited – Nicholls v Coroner for City of Liverpool Admn 8-Nov-2001
As the deceased was arrested he swallowed something. He was examined by a doctor and denied that he had swallowed drugs, but his condition deteriorated and he died at hospital. The coroner refused to admit the evidence of a professor who was highly . .
Cited – Regina (Dawson) v HM Coroner for East Riding and Kingston upon Hull Admn 2001
. .
Lists of cited by and citing cases may be incomplete.

Coroners, Human Rights

Updated: 05 June 2022; Ref: scu.168731

Keenan v The United Kingdom: ECHR 3 Apr 2001

A young prisoner was known to be at risk of suicide, but nevertheless was not provided with adequate specialist medical supervision. He was punished for an offence, by way of segregation which further put him at risk.
Held: Inhuman and degrading treatment had to achieve a certain standard of seriousness before it became an infringement, but after that might be relative to the circumstances. The court must also see whether an intention existed to debase and humiliate the person subjected to the treatment.
Despite the known risk, and identifiably increased risks, there were no medical notes for a period. The offence itself may have followed an unconsidered change in his medication. His article 3 rights had been infringed. Ill-treatment must attain a minimum level of severity if it is to fall within the scope of Article 3. The ‘inquest, which did not permit the determination of issues of liability, did not furnish the applicant with the possibility of establishing the responsibility of the prison authorities or obtaining damages.’ and ‘Given the fundamental importance of the right to the protection of life, Article 13 requires, in addition to the payment of compensation where appropriate, a thorough and effective investigation capable of leading to the identification and punishment of those responsible for the deprivation of life.’
Hudoc Judgment (Merits and just satisfaction) No violation of Art. 2; Violation of Art. 3; Violation of Art. 13; Non-pecuniary damage – financial award; Costs and expenses partial award

Citations:

Times 18-Apr-2001, 27229/95, (2001) 33 EHRR 38, [2001] ECHR 239, [2001] 10 BHRC 319, [2001] ECHR 242, (2001) 33 EHRR 913, [2011] ECHR 2266

Links:

Worldlii, Bailii, Bailii

Statutes:

European Convention on Human Rights Art 3

Citing:

Cited – Salman v Turkey ECHR 27-Jun-2000
Where someone dies or is injured whilst in custody the burden is on the state to provide a ‘satisfactory and convincing explanation’ of what has happened: ‘Persons in custody are in a vulnerable position and the authorities are under a duty to . .

Cited by:

Cited – Munjaz v Mersey Care National Health Service Trust And the Secretary of State for Health, the National Association for Mental Health (Mind) Respondent interested; CA 16-Jul-2003
The claimant was a mental patient under compulsory detention, and complained that he had been subjected to periods of seclusion.
Held: The appeal succeeded. The hospital had failed to follow the appropriate Code of Practice. The Code was not . .
Cited – PS, Regina (on the Application of) v Responsible Medical Officer, Dr G and others Admn 10-Oct-2003
The claimant had been compulsorily detained under the Act. He complained that the detention and compulsory medication infringed his rights, and amongst other things breached his religious beliefs.
Held: This was an exceptional case requiring . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – E v Channel Four, News International Ltd and St Helens Borough Council FD 1-Jun-2005
The applicant sought an order restraining publication by the defendants of material, saying she did not have capacity to consent to the publication. She suffered a multiple personality disorder. She did herself however clearly wish the film to be . .
Cited – Van Colle v Hertfordshire Police QBD 10-Mar-2006
The claimants claimed for the estate of their murdered son. He had been waiting to give evidence in a criminal trial, and had asked the police for support having received threats. Other witnesses had also suffered intimidation including acts of . .
Cited – Van Colle and Another v Chief Constable of the Hertfordshire Police CA 24-Apr-2007
The deceased had acted as a witness in an intended prosecution. He had sought protection after being threatened. No effective protection was provided, and he was murdered. The chief constable appealed a finding of liability.
Held: The . .
Cited – JL, Regina (on the Application of) v Secretary of State for Justice; Regina (L (A Patient)) v Secretary of State for the Home Department HL 26-Nov-2008
The prisoner was left with serious injury after attempting suicide in prison. He said that there was a human rights duty to hold an investigation into the circumstances leading up to this.
Held: There existed a similar duty to hold an enhanced . .
Cited – Savage v South Essex Partnership NHS Foundation Trust (MIND intervening) HL 10-Dec-2008
The deceased had committed suicide on escaping from a mental hospital. The Trust appealed against a refusal to strike out the claim that that they had been negligent in having inadequate security.
Held: The Trust’s appeal failed. The fact that . .
Cited – Bary and Others, Regina (on The Application of) v Secretary of State for Justice and Another Admn 19-Mar-2010
The applicants, incarcerated at Long Lartin pending extradition or deportation, challenged a decision further restricting their movements within the prison. All were unconvicted, and all but one were suspected of terrorist crimes. The changes were . .
Cited – Rabone and Another v Pennine Care NHS Trust CA 21-Jun-2010
The claimant’s daughter had committed suicide after being given home leave on a secure ward by the respondent mental hospital. A claim in negligence had been settled, but the parents now appealed refusal of their claim that the hospital had failed . .
Cited – Rabone and Another v Pennine Care NHS Foundation SC 8-Feb-2012
The claimant’s daughter had committed suicide whilst on home leave from a hospital where she had stayed as a voluntary patient with depression. Her admission had followed a suicide attempt. The hospital admitted negligence but denied that it owed . .
Lists of cited by and citing cases may be incomplete.

Human Rights, Coroners

Updated: 04 June 2022; Ref: scu.166065

Regina v Her Majesty’s Coroner for Inner London North ex parte Peter Francis Touche: CA 21 Mar 2001

The applicant’s wife had died of a cerebral haemorrhage, the result of severe hypertension, possibly secondary to eclampsia. The coroner decided not to hold an inquest. The issue raised was whether he was required to hold an inquest because there was reasonable cause to suspect that she had died an unnatural death.
Held: The coroner was wrong to conclude that a death was not unnatural within the Act where the death had occurred at a hospital when the hospital had failed adequately to monitor her blood pressure. The failure of a hospital to maintain standards of care was of concern to the public, and one of the coroners. Costs were awarded to the claimant both at the Court of Appeal and at the High Court, against the coroner when directing a new inquest into the death when there was no other means of indemnifying him for the expense to which he had been put, even though the coroner was a judicial officer who had conducted himself impeccably.

Citations:

Gazette 17-May-2001, [2001] EWCA Civ 383, [2001] QB 1206

Links:

Bailii

Statutes:

Coroners Act 1988 8(1)(a)

Jurisdiction:

England and Wales

Citing:

Doubted – Regina v Lincoln Coroner, Ex Parte Hay Admn 19-Feb-1999
Coroners Society recommended to publish pre-trial guidelines and prepare a list of witnesses to be called showing in each case a brief summary of the evidence expected to be given by that witness in order to assist parties at inquests. A costs order . .

Cited by:

Cited – Regina on the Application of Davies (No 2) v HM Deputy Coroner for Birmingham CA 27-Feb-2004
The claimant appealed against a costs order. She had previously appealed against an order of the High Court on her application for judicial review of the inquest held by the respondent.
Held: The coroner, and others in a similar position . .
Cited – Corner House Research, Regina (on the Application of) v Secretary of State for Trade and Industry CA 1-Mar-2005
The applicant sought to bring an action to challenge new rules on approval of export credit guarantees. The company was non-profit and founded to support investigation of bribery. It had applied for a protected costs order to support the . .
Lists of cited by and citing cases may be incomplete.

Coroners, Costs

Updated: 31 May 2022; Ref: scu.147476

In re Maddison (Deceased): QBD 18 Nov 2002

An application was made to re-open the inquest into the death of member of the armed forces who had taken part in a gas experiment in 1953.
Held: In rare circumstances, it could be appropriate to order an inquest to be re-opened. Here, material facts had not been made known to the coroner, and the inquest had been held in camera, and despite the passage of time much documentary material remained. Together, that was sufficient to justify another inquest.

Judges:

Woolf LCJ, Hallett, J

Citations:

Times 28-Nov-2002

Jurisdiction:

England and Wales

Coroners

Updated: 30 May 2022; Ref: scu.178268

Commissioner of the Police of the Metropolis v Inner London Coroner: QBD 31 Oct 2002

The applicant sought the quashing of an inquest verdict, and for a new inquest. The coroner resisted claiming that it would put too great a strain on his resources.
Held: The section allowed a coroner to appoint a deputy who would be able to hold the inquest. The words ‘in his absence’ could include occasions when the coroner was himself engaged on an inquest.

Judges:

Pitchers J, Kennedy LJ

Citations:

Times 11-Nov-2002, Gazette 28-Nov-2002

Statutes:

Coroners Act 1988 7

Jurisdiction:

England and Wales

Coroners

Updated: 29 May 2022; Ref: scu.178040

Regina v Her Majesty’s Coroner for District of Avon ex parte Smith: Admn 12 Feb 1998

The family sought judicial review of a decision not to hold an inquest into the death of the deceased. The child had died in hospital.
Held: The death had apparently been for natural causes, but the coroner had failed properly to ask himself whether the death was unnatural in the sense used in Regina -v- Poplar Coroner ex parte Thomas. His decision was flawed.

Judges:

Ognall J

Citations:

[1998] EWHC Admin 174

Links:

Bailii

Statutes:

Coroners Act 1988 8(1)

Jurisdiction:

England and Wales

Citing:

Cited – Regina v Poplar Coroner ex parte Thomas CA 15-Dec-1992
The deceased, aged 17, had had a severe asthma attack. The ambulance was delayed and she was taken to the hospital, but died on the way there despite assistance from police officers and latterly the ambulance staff. Evidence suggested that she might . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 27 May 2022; Ref: scu.138295

In re Rapier (Deceased): QBD 1988

A young prisoner had been found dead in his cell hanging. A report suggested that he may have been sniffing solvents. The coroner himself initiated proceedings both under the Coroners’ Act and for judicial review to quash the inquisition over which he had presided in the light of new evidence which had later come to light. There was no respondent to the application, merely counsel appointed as amicus curiae.
Held: The application was granted. Amongst the ‘compelling grounds for ordering a fresh inquest’, were that ‘the coroner himself believes it to be necessary and has indeed initiated the application’. It is the coroner himself who must seek a new inquest, bearing in mind the reasonable concerns of the family of the deceased. When the court considers ordering a new inquest, it must look at the likelihood of a different verdict.
Woolf LJ said that it was not necessary to show that it was likely that a different verdict would be reached to order a new inquest, only that a different verdict might be reached: ‘This appears to be a much more satisfactory approach because, in many cases, and I would include this case as an example, it will be quite impossible to say what will be the effect of the new evidence. The effect which it will have will only be known after the witnesses have given their evidence and have been questioned. They may then be believed or they may not be believed. However, whatever the outcome, it still may be in the interests of justice that their evidence should be explored in public before a jury.’
Simon Brown J said: ‘In many cases it will be quite impossible for the reviewing court . . to form any sensible view upon whether the new evidence creates a probability or only a possibility that a different verdict would be arrived at upon a fresh inquisition. That would generally depend upon the precise evidence eventually given and the credibility of the witnesses that give it . . this is not to say, however, that it will not generally be of the first importance to consider so far as possible the likelihood or otherwise of a fresh inquest arriving at a different verdict. That will always be relevant, often critical and sometimes wholly decisive, not least in ‘new facts or evidence’ cases.’

Judges:

Woolf LJ, Simon Brown J

Citations:

[1988] 1 QB 26

Statutes:

Coroners act 1988 13

Jurisdiction:

England and Wales

Cited by:

Cited – Gough v Local Sunday Newspapers (North) Ltd and Another CA 12-Mar-2003
The appellant claimed he had been libelled, when he was called incompetent by the respondent in the way he dealt with finding an uncounted bundle of votes after an election. He appealed a finding of justification. The finding was based upon an . .
Cited – In the Matter of Captain Christopher John Kelly Admn 14-Jun-1996
The deceased was killed by ‘friendly fire’ during a night exercise in Kenya. A verdict of accidental death was returned, and a fresh inquest was sought particularly in the light of a statement from a fellow officer.
Held: The emergence of . .
Cited – Parkin v HM Coroner for North Lincolnshire and Grimsby District Admn 23-Mar-2005
The family appealed against an open verdict. Her son was found hanged at school. The coroner felt unable to be sure that he had committed suicide. He had been looking forward to a new job as a theatre technician.
Held: There was evidence . .
Cited – Bloom v HM Assistant Deputy Coroner for the Northern District of London and Another Admn 20-Dec-2004
The deceased had gone to hospital and was diagnosed as having a kidney stone. As it was removed there was evidence of infection. She declined and was transferred to the local NHS hospital in intensive care. She died and a post-mortem identified . .
Cited – Sutovic, Regina (on the Application Of) v HM Coroner for North London Admn 17-May-2006
The court heard an application for judicial review of the Coroner’s verdict, on the grounds of procedural irregularity and insufficiency of enquiry. The claimant also sought a new review in the light of more recently received evidence.
Held: . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 26 May 2022; Ref: scu.179773

In re Catherine Lucy Clegg (an Application to Quash Inquisition on Inquest): Admn 2 Dec 1996

The father of the deceased sought an order quashing the inquest on her death. He had recorded a verdict of suicide. She had died from acute salicylate poisoning, an aspirin overdose. The hospital was said not to have recognised her condition and not to have taken steps to prevent the result. She had left a suicide note.

Judges:

Phillips LJ, Hooper J

Citations:

[1996] EWHC Admin 307

Links:

Bailii

Statutes:

Coroners Act 1988 13

Citing:

Cited – Regina v Coroner for Surrey, ex parte Wright 18-Jun-1966
The deceased died when unconscious under general anaesthetic in the course of dental surgery, as a result of an obstruction to his airway.
Held: There was no basis in such circumstances for contending that the verdict of accident should have . .
Cited – Regina v Birmingham Coroner, ex parte Cotton QBD 1995
The Coroner’s court is not the proper place to explore questions of clinical negligence. . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson QBD 12-Jul-1993
A prisoner had hanged himself after being left unsupervised in a single cell. He was a known suicide risk, but the Coroner directed the jury not to return a verdict which included any reference to lack of care.
Held: A coroner was free not to . .
Cited – Regina v Portsmouth Coroner, ex parte Anderson 1988
. .
Cited – Regina v Southwark Coroner, ex parte Hicks QBD 1987
The verdict of ‘lack of care’ at an inquest is to be used to indicate only the condition of the deceased at the time of death as a cause of death, and is not to be used as a way of attributing fault. The admission of documentary evidence by a . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 25 May 2022; Ref: scu.136855

Sreedharan, Regina (on The Application of) v HM Coroner for The County of Greater Manchester: Admn 28 May 2012

The claimant doctor renewed his application for judicial review of the jury verdict of unlawful killing at the inquest into a patient. The patientwas alcoholic. The doctor prescribed a sedative drug for him, but it was known to be potentially lethal when taken with alcohol. The patient had used them in combination on previous occasions. The doctor said that the coroner had allowed the inquest to stray beyond the matters allowed under the Rules.
Held: The request failed. The case presented was unarguable.
The claimant’s credibility was unavoidably in issue, the evidence as to potential fault in others was examined at length, and the coroner had left such as a potential alternative verdict.

Judges:

Foskett J, Peter Thornton QC

Citations:

[2012] EWHC 1386 (Admin)

Links:

Bailii

Statutes:

Coroners Rules 1984 36(1), Coroners Act 1988

Jurisdiction:

England and Wales

Citing:

Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – Regina v Lincoln Coroner, Ex Parte Hay Admn 19-Feb-1999
Coroners Society recommended to publish pre-trial guidelines and prepare a list of witnesses to be called showing in each case a brief summary of the evidence expected to be given by that witness in order to assist parties at inquests. A costs order . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 23 May 2022; Ref: scu.459830

Regina v Lincoln Coroner, Ex Parte Hay: Admn 19 Feb 1999

Coroners Society recommended to publish pre-trial guidelines and prepare a list of witnesses to be called showing in each case a brief summary of the evidence expected to be given by that witness in order to assist parties at inquests. A costs order might be made against a coroner when: (1) If a coroner not only filed an affidavit but also appeared and contested the making of an adverse order in an inter partes adversarial mode, then he or she was at risk as to costs; (2) If on the other hand, the coroner, as was fitting for somebody holding judicial office, swore an affidavit to assist the court and then appeared in court, more in the role of an amicus rather than as a contesting party, then the court was likely to follow the normal rule set out in Jervis and make no order as to costs provided that it did not express strong disapproval of his or her conduct.
Brooke LJ said: ‘We are unwilling for our part, to fetter the discretion of a coroner by being at all prescriptive about the procedures he should adopt in order to achieve a full, fair and thorough hearing.’

Judges:

Forbes J, Brooke LJ

Citations:

Times 30-Mar-1999, [1999] EWHC Admin 155, [2000] Lloyd’s Med LR 264

Links:

Bailii

Citing:

Doubtd – Regina v Coroner for Wiltshire ex parte Clegg QBD 1996
The court awarded costs against a coroner on an appeal even though he had only taken part by the filing of an affidavit. . .

Cited by:

Cited – Regina on the Application of Davies (No 2) v HM Deputy Coroner for Birmingham CA 27-Feb-2004
The claimant appealed against a costs order. She had previously appealed against an order of the High Court on her application for judicial review of the inquest held by the respondent.
Held: The coroner, and others in a similar position . .
Doubted – Regina v Her Majesty’s Coroner for Inner London North ex parte Peter Francis Touche CA 21-Mar-2001
The applicant’s wife had died of a cerebral haemorrhage, the result of severe hypertension, possibly secondary to eclampsia. The coroner decided not to hold an inquest. The issue raised was whether he was required to hold an inquest because there . .
Cited – Sreedharan, Regina (on The Application of) v HM Coroner for The County of Greater Manchester Admn 28-May-2012
The claimant doctor renewed his application for judicial review of the jury verdict of unlawful killing at the inquest into a patient. The patientwas alcoholic. The doctor prescribed a sedative drug for him, but it was known to be potentially lethal . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 19 May 2022; Ref: scu.85369

Regina v Southwark Coroner’s Court ex parte Epsom Health Care NHS Trust: 1993

Steyn LJ said that an inquest should not be used as a stepping stone to civil litigation.
An inquest verdict may be set aside in part as well as as a whole. A lack of care finding was deleted but the remainder of the verdict remained.

Judges:

Steyn LJ

Citations:

[1993] 158 JP 973

Jurisdiction:

England and Wales

Coroners

Updated: 18 May 2022; Ref: scu.618965

Case 22 H 6, 51 12 E 4, Ch 1 13 E 4, 6 Process, Viscount By The Judges of Both Benches Co Lit 157 B Hob 139: 1220

In case of the death or removal of a sheriff before the end of his year; no new process shall issue until a new sheriff is made, but shall wait till then, and not be directed to the coroners : but if issue be joined, and the plaintiff suggests to the court that the sheriff is his cousin, and the defendant does not deny it ; process shall issue to the coroners to speed the suit. So if it be suggested in Chancery, and not denied by the other party, that the sheriff is plaintiff, or defendant in the suit; the writ shall be directed by the coroners. [*By the statutes of 12 E. 4, ch. 1, and 17 E. 4, ch. 6, after the end of Michaelmas and Hillary terms, no writ or process shall be directed to the old sheriff, for the sheriff is not to continue in his office any longer. ] Where a sheriff makes a false or insufficient return, he shall be fined or amerced, as the case requires : but notwithstanding these misdemanours, the writ shall continue to be directed to him, and not to the coroners.

Citations:

[1220] EngR 335, (1220-1623) Jenk 99, (1220) 145 ER 71 (A)

Links:

Commonlii

Coroners

Updated: 18 May 2022; Ref: scu.461247

Regina (Pereira) v Inner South London Coroner and Others: QBD 14 Jun 2007

The applicant sought to challenge a decision to adjourn an inquest.
Held: A decision as to whether an inquest should be adjourned was one within the coroner’s discretion. Provided he had acted rationally and taken into account the relevant factors, his decision could not be challenged by way of judical review.

Judges:

Laws LJ, Mitting J

Citations:

Times 22-Jun-2007

Jurisdiction:

England and Wales

Coroners

Updated: 17 May 2022; Ref: scu.263550

Anderson v Blashki: 1993

(Supreme Court of Victoria) The civil standard of proof applies to all findings of coroners although the graver the allegation, the more cogent must be the evidence.

Citations:

[1993] 2 VR 89

Jurisdiction:

Australia

Cited by:

Cited – Regina v Southwark Coroner ex parte Fields Admn 30-Jan-1998
The deceased died after being hit by a policemen with his baton when being arrested. The verdict of misadventure was now challenged. The police officer said he had hit out in fear of imminent attack. It was said that the Coroner had permitted those . .
Lists of cited by and citing cases may be incomplete.

Commonwealth, Coroners, Evidence

Updated: 17 May 2022; Ref: scu.237534

Regina v Southwark Coroner, ex parte Hicks: QBD 1987

The verdict of ‘lack of care’ at an inquest is to be used to indicate only the condition of the deceased at the time of death as a cause of death, and is not to be used as a way of attributing fault. The admission of documentary evidence by a coroner is controlled by Rule 37 and that the use of and reference to documents is narrowly circumscribed. In this case the issue of ‘lack of care’ should have been investigated and left to the jury.

Judges:

Croom Johnson LJ

Citations:

[1987] 1 WLR 1624, [1987] 2 All ER 140

Jurisdiction:

England and Wales

Cited by:

Cited – In re Catherine Lucy Clegg (an Application to Quash Inquisition on Inquest) Admn 2-Dec-1996
The father of the deceased sought an order quashing the inquest on her death. He had recorded a verdict of suicide. She had died from acute salicylate poisoning, an aspirin overdose. The hospital was said not to have recognised her condition and not . .
Cited – Assistant Deputy Coroner of Inner West London v Paul and Another, Regina on the Application of CA 28-Nov-2007
The coroner appealed a judicial review granted after he allowed into evidence, hearsay evidence contained in a written statemnent from a witness who could not attend the inquest.
Held: Rule 37 does not allow the admission of a document, even . .
Cited – Hurst, Regina (on the Application of) v Commissioner of Police of the Metropolis v London Northern District Coroner HL 28-Mar-2007
The claimant’s son had been stabbed to death. She challenged the refusal of the coroner to continue with the inquest with a view to examining the responsibility of any of the police in having failed to protect him.
Held: The question amounted . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 17 May 2022; Ref: scu.237541

A and Another v Inner South London Coroner: QBD 24 Jun 2004

At an inquest into the death of a civilian apparently shot by police officers, the officers applied for anonymity, which the coroner refused. They sought judicial review.
Held: How witnesses participated in coroners inquests was to be decided on a case by case basis. A witness seeking anonymity had to establish both a subjective fear and reasonable objective grounds. Once those were established, the court could carry out a balancing exercise. In this case the coroner had failed to ask the two first questions together. In this case the request was that anonimity be preserved until the announcement of the verdict. This would protect the officers’ families and seemed to meet the demands of justice.

Judges:

Mitting J

Citations:

Times 12-Jul-2004

Jurisdiction:

England and Wales

Citing:

Cited – A and Others, Regina (on the Application of) v Lord Saville of Newdigate and others CA 28-Jul-1999
Former soldiers who had been involved in the events in Londonderry in 1972, and were to be called to give evidence before a tribunal of inquiry, still had cause to fear from their names being given, and so were entitled to anonymity when giving such . .
Cited – Regina v Governor of Pentonville Prison, Ex parte Fernandez: Fernandez v Government of Singapore HL 1971
Test for police protection need
The court considered the degree of risk to an individual which should give rise to a duty on the police to protect him under article 2.
Held: Lord Diplock said: ‘My Lords, bearing in mind the relative gravity of the consequences of the court’s . .
Appealed to – Regina (A and Another) v Inner South London Coroner CA 2-Nov-2004
Police officers sought anonymity when asked to appear before a coroner’s court, citing fear of violence if named. The family of the deceased appealed an order granting that to them.
Held: The coroner had heard evidence that a family member had . .

Cited by:

Appeal from – Regina (A and Another) v Inner South London Coroner CA 2-Nov-2004
Police officers sought anonymity when asked to appear before a coroner’s court, citing fear of violence if named. The family of the deceased appealed an order granting that to them.
Held: The coroner had heard evidence that a family member had . .
Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 16 May 2022; Ref: scu.199972

Regina on the Application of Challender, and Morris v The Legal Services Commission: Admn 29 Apr 2004

Judges:

Mr Justice Richards

Citations:

[2004] EWHC 925 (Admin)

Jurisdiction:

England and Wales

Citing:

See Also – Challender and Another, Regina (on the Application of) v Legal Services Commission Admn 29-Apr-2004
. .
Lists of cited by and citing cases may be incomplete.

Coroners, Legal Aid

Updated: 16 May 2022; Ref: scu.196056

Regina v Shrewsbury Coroner’s Court ex parte British Parachute Association: QBD 21 Sep 1987

Coroners are forbidden by the rules to make recommendations to a jury as to their verdict. Despite the fact that the coroner was represented at the appeal, the court refused to make any order for costs against the coroner. This was not a case where they could express strong disapproval of the coroner, there being no special circumstances .

Judges:

Lloyd LJ and Mann J

Citations:

(1987) 152 JPR 123, Times 21-Sep-1987

Statutes:

Coroners Rules 1984 (1984 No 552) 36(2)

Jurisdiction:

England and Wales

Cited by:

Cited – Regina on the Application of Davies (No 2) v HM Deputy Coroner for Birmingham CA 27-Feb-2004
The claimant appealed against a costs order. She had previously appealed against an order of the High Court on her application for judicial review of the inquest held by the respondent.
Held: The coroner, and others in a similar position . .
Lists of cited by and citing cases may be incomplete.

Coroners, Costs

Updated: 16 May 2022; Ref: scu.194541