Greenough v Ministry of Justice: Admn 11 Sep 2013

Application for permission to continue judicial review proceedings, permission having been refused on the papers.
The challenge is brought by the claimant against a refusal by the Ministry of Justice to authorise exceptional funding, pursuant to section 6(8) subparagraph (b) of the Access to Justice Act 1999 for representation at an inquest into the death of her brother, who it is common ground died in his own home on 8th February 2012, on the day following his discharge from hospital.

Pelling QC HHJ
[2013] EWHC 3112 (Admin)
Bailii
Access to Justice Act 1999 6(8)
England and Wales

Coroners, Legal Aid

Updated: 22 November 2021; Ref: scu.516590

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: The first claim failed. As to the second, Moses LJ said: ‘Whilst, on the state of the evidence at present, any other verdict than an open verdict may seem unlikely, we are persuaded that in the light of the evidence which has emerged since the coroner’s verdict a fresh inquest should be ordered . .
In the present case in the inquest verdict the coroner did record some circumstances . . and in particular that there was no evidence as to the exact circumstances surrounding the death. But it appears that there is evidence of at least some of the circumstances surrounding the death. Those circumstances have never been fully investigated and indeed could not be investigated since that evidence had not yet emerged, at the time of the verdict on 27 September 2004. The evidence includes the report of the Serbian Ministry of Interior Affairs dated 11 April 2005, the reports of doctors Milosavljevic and Gavalas as to the appearance of the deceased and to the presence of blood at the scene.
If, after examination of the circumstances at a fresh inquest, it emerges that the deceased had been treated with violence at the time of his death, even if that only leads to another open verdict, that seems to us to be a conclusion very different from that which already had been reached . . The evidence which has now emerged may cast a very different light upon the circumstances of Petar Sutovic’s death. In those circumstances we would allow the application under Section 13 and order a fresh inquest before a different coroner.
We should emphasise that our conclusion is based on a very small amount of the material before us and despite the over abundance of argument, evidence and experts’ reports. It will be for the coroner conducting a full and fair fresh inquest to sift that which is of use and that which is without foundation. The claimant’s grief deprived her of the ability to do so in prosecuting either the judicial review proceedings or the claim under Section 13 of the 1988 Act. Many of her concerns are not legitimate and have been fuelled by experts reports, some of which we consider are flawed for the reasons we have set out, in particular the apparent non disclosure to those instructed by or on behalf of the claimant of the Serbian Ministry of Interior Affairs’ report demonstrating the inadequacies of the original investigation and the fact that the scene of the death was not sealed. Notwithstanding this, it seems to us that the public interest requires that should be done, if only to allay the fears and suspicions which have already, possibly unnecessarily been aroused’.
Moses LJ considered the aplication of section 13, saying: ‘The power contained in section 13(1)(b) is stated in very broad terms. The necessity or desirability of another inquest may arise by reasons of one of the listed matters or ‘otherwise’. Notwithstanding the width of the statutory words, its exercise by the courts shows that the factors of central importance are an assessment of the possibility (as opposed to the probability) of a different verdict, the shortcomings in the original inquest, and the need to investigate matters raised by new evidence which had not been investigated at the inquest: see Re Rapier [1988] 1 QB 26, 34-35, 37H-38A, 39 per Woolf LJ and Simon Brown J; R v HM Coroner, Lincoln, ex p Hay. 19 February 1987; R v HM Coroner, Coventry, ex p O’Reilly. Times Law Reports, 3 April 1996; and R v Assistant Deputy Coroner for Northern District of London, ex p Bloom [2004] EWHC 3071 (Admin) . . ‘

Moses LJ, Beatson J
[2006] EWHC 1095 (Admin)
Bailii
Coroners Act 1988 13
England and Wales
Citing:
CitedRegina v HM Coroner, Lincoln, ex parte Hay 19-Feb-1987
. .
CitedIn 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 by:
See AlsoHM Coroner for the Eastern District of London, Regina (On the Application of) v Sutovic Admn 31-Jul-2009
The deceased had died in Serbia, but was buried in Acton. A second inquest had been ordered on the request of the respondent, and an exhumation licence granted for the purposes of a second post mortem examination. The respondent had refused her . .

Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 17 November 2021; Ref: scu.241780

McDonnell v The United Kingdom: ECHR 9 Dec 2014

The applicant complained in particular under Article 2 that the State had not fulfilled its procedural, investigative obligation in respect of the death in custody of her son in that there had been an excessive delay in the inquest proceedings.
Held: The delay was a breach. Award accordingly.

Ineta Ziemele, P
19563/11 – Chamber Judgment, [2014] ECHR 1370
Bailii
European Convention on Human Rights
Human Rights

Human Rights, Coroners

Updated: 15 November 2021; Ref: scu.539814

Worcestershire County Council and Another v HM Coroner for The County of Worcestershire: QBD 20 Jun 2013

The court considered the request by the coroner for the production to him of draft overview report prepared by the respondent with its supporting reports on the work of individual officers.

Jeremy Baker J
[2013] EWHC 1711 (QB)
Bailii
England and Wales
Cited by:
CitedSecretary of State for The Home Department v HM Senior Coroner for Surrey and Others Admn 23-Nov-2016
The Home Secreary requested approval for the withholding of documents from a coroner’s inquest on the ground that disclosure would damage the public interest. The deceased had died whilst jogging, and there was a possibility that he had been . .

Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 14 November 2021; Ref: scu.510962

CM v The Executor of The Estate of EJ and Others: FD 14 Jun 2013

CM, a medical doctor stoppd in the street and atended a woman who had fallen from a building, and later died. In caring for her, she had contact with the lady’s blood. Her own hands had broken skin, anf being afraid of blood borne disease sought an order for blood to be taken for analysis.
Held: Granted

Cobb J
[2013] EWHC 1680 (Fam)
Bailii
Human Tissue Act 2004
England and Wales

Coroners, Health

Updated: 14 November 2021; Ref: scu.510875

The Secretary of State, Regina (on The Application of) v HM Senior Coroner for Norfolk and Another: Admn 28 Sep 2016

Coroner may not use flight records

The coroner was charged to investigate four deaths in an helicopter accident. The Secretary of State now challenged various decisions of the Coroner by which (i) she ordered disclosure to her of a cockpit voice and flight data recorder and/or a full transcript of that voice recording; and (ii) she imposed a fine for non-compliance with those orders.
Held: The request for judiial review succeeded. The 1944 Convention applied to restrict the use of such recordings save where disclosure outweighs the adverse domestic and international impact such action may have on that or any future investigations.

Lord Thomas of Cwmgiedd CJ, Singh J
[2016] EWHC 2279 (Admin)
Bailii
Coroners and Justice Act 2009, Convention on International Civil Aviation 1944
England and Wales

Coroners, Transport

Updated: 11 November 2021; Ref: scu.569629

Patel, Regina (on The Application of) v Lord Chancellor: Admn 27 Aug 2010

No Right to Legal Aid for Inquest

The claimant challenged the refusal to her of assistance toward her legal costs in securing representation at the coroner’s inquest into the bombings in London in July 2005. He husband was suspected of being one of the suicide bombers.
Held: There was no right to funding at an inquest, and specific authority was required and to be given only where there was a proper public interest in such representation. The threshold for such funding was high. Funding had been given to families of the victims, with a potential of the client’s involvement producing real benefits for individuals other than the client. The application did not meet that test. If such applications were to be made, they must be made in a timely manner. This application had not been made in such a manner.

Thomas LJ, Silber J
[2010] EWHC 2220 (Admin), [2011] ACD 5, [2010] WLR (D) 240, [2010] Inquest LR 188
Bailii
Access to Justice Act 1999 1, Senior Courts Act 1981 31(6)
England and Wales
Citing:
CitedFinn-Kelcey v Milton Keynes Council and MK Windfarm Ltd CA 10-Oct-2008
Judicial Review must be timely
The appellant challenged the grant of permission for a wind farm on neighbouring land. His application for judicial review had been rejected for delay and on the merits.
Held: The court repeated the requirement that an application must be both . .

Lists of cited by and citing cases may be incomplete.

Coroners, Legal Aid

Updated: 11 November 2021; Ref: scu.421893

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. The applicants believed this would require a further investigation of the planning and control of the operation in which the deaths occurred.
Held: The appeal was allowed (Lord Rodger dissenting). The Coroner would have to hold an inquest complying with Article 2.
The Convention was a living instrument, and must be read as applied from time to time. In Silih, the Grand Chamber had departed from its earlier views, finding that in some circumstances the procedural duty to hold a compliant investigation could be detachable and operate as a freestanding one. Before Silih, the jurisprudence in Strasbourg had been that: ‘the procedural obligation was initially closely related to the substantive obligation that article 2 imposed on the state. The object of the procedural obligation was to check whether there had been a breach of the substantive obligation. If the substantive obligation did not exist the procedural obligation could not exist either.’ The decision if McKerr must be read accordingy. Though the Human Rights was not retrospective in effect, ‘the ambit of application of the Act should mirror that of the Convention. The object of the Act was to bring human rights home. This will only be achieved if claimants are able to bring in this jurisdiction claims that they would otherwise be permitted to bring before the Strasbourg Court. ‘

Lord Phillips, President, Lord Hope, Deputy President, Lord Rodger, Lady Hale, Lord Brown, Lord Kerr, Lord Dyson
[2011] UKSC 20, [2011] 3 All ER 607, [2011] 2 WLR 1279, UKSC 2010/0101
Bailii, Bailii Summary, SC, SC Summary
European Convention on Human Rights 2, Human Rights Act 1996
Northern Ireland
Citing:
At first instanceMcCaughey and Quinn, Re Judicial Review QBNI 23-Sep-2009
The claimants sought leave to apply for Judicial Review of a decision of the Coroner in relation to the Inquests yet to be held into the deaths in 1990 of Martin McCaughey and Dessie Grew at the hands of members of the security forces. The claimants . .
Appeal fromMcCaughey 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 . .
CitedMcCann and Others v The United Kingdom ECHR 6-Oct-1995
mccann_ukECHR1995
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 . .
CitedIn 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 . .
CitedMoldovan And Others v Romania (No. 1) ECHR 12-Jul-2005
In 1993 a pogrom had taken place in a Roma village, resulting in a number of deaths and widespread destruction of property. The State, in the form of the local police, was alleged to have been implicated. Romania acceded to the Convention on 20 June . .
CitedSilih v Slovenia ECHR 9-Apr-2009
(Grand Chamber) Article 2 imposes, in certain circumstances, a freestanding obligation in relation to the investigation of a death which applied even where the death itself had occurred before the member state ratified the Convention.: ”The court . .
CitedJordan 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 . .
CitedHurst, 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 . .
CitedSmith, 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.
CitedKaya v Turkey ECHR 19-Feb-1998
Hudoc Judgment (Merits and just satisfaction) Preliminary objection rejected (locus standi); No violation of Art. 2, not established that applicant . .
CitedMcDaid v United Kingdom ECHR 1996
(Commission) Decision on admissibility. Residents of Derry applied alleging inter alia that there had been a breach of the procedural obligation under article 2 to hold a full investigation into the ‘Bloody Sunday’ killings in 1972. They alleged . .
CitedRegina v Lambert HL 5-Jul-2001
Restraint on Interference with Burden of Proof
The defendant had been convicted for possessing drugs found on him in a bag when he was arrested. He denied knowing of them. He was convicted having failed to prove, on a balance of probabilities, that he had not known of the drugs. The case was . .
CitedLyubov Efimenko v Ukraine ECHR 25-Nov-2010
The applicant was the mother of a young man who was robbed and killed in an attack in a bar. He died on 6 June 1993, four years and three months before the Convention came into force in relation to Ukraine. Investigations were suspended shortly . .
CitedVarnava And Others v Turkey ECHR 10-Jan-2008
Where an individual had disappeared in circumstances raising a suspicion that he may have been killed, article 2 imposes a continuing duty to investigate the death. In this case the duty was said to have persisted for 34 years since the . .
CitedRegina 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 . .
CitedWilson v Secretary of State for Trade and Industry; Wilson v First County Trust Ltd (No 2) HL 10-Jul-2003
The respondent appealed against a finding that the provision which made a loan agreement completely invalid for lack of compliance with the 1974 Act was itself invalid under the Human Rights Act since it deprived the respondent of its property . .
CitedBrecknell v The United Kingdom ECHR 27-Nov-2007
Allegations had been made about police collusion with killings in Northern Ireland.
Held: Where there was credible information as to a possible perpetrator of an unlawful killing, there was a duty to investigate that evidence. Here the . .
CitedAngelova And Iliev v Bulgaria ECHR 26-Jul-2007
The applicants were mother and brother of a Roma man who had been stabbed to death by a gang of teenagers. They did not suggest any direct involvement of the state, but complained of inadequacies in the police investigation.
Held: The absence . .
CitedBalasoiu -c- Roumanie ECHR 20-Apr-2004
The applicant complained of being beaten up by police in 1993, before Romania had acceded to the Convention, but also of delay in the procedural investigation, which was still ongoing.
Held: The latter complaint was admissible. The court did . .
CitedRegina v Secretary of State for Foreign and Commonwealth Affairs ex parte Quark Fishing Limited HL 13-Oct-2005
The applicant had previously received licences to fish for Patagonian Toothfish off South Georgia. The defendant had instructed the issuer of the licence in such a way that it was not renewed. It now had to establish that its article 1 rights had . .
CitedSecretary of State for Defence v Al-Skeini and others (The Redress Trust Intervening) HL 13-Jun-2007
Complaints were made as to the deaths of six Iraqi civilians which were the result of actions by a member or members of the British armed forces in Basra. One of them, Mr Baha Mousa, had died as a result of severe maltreatment in a prison occupied . .
CitedVoroshilov v Russia ECHR 8-Dec-2005
The applicant alleged that he had been tortured by the police in 1997, the year before the Convention came into force in the Russian Federation. Criminal proceedings were commenced in 1997 but had not concluded. The applicant claimed that the state . .
See AlsoMcCaughey 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 AlsoPolice Service of Northern Ireland v McCaughey and Another CANI 14-Jan-2005
. .

Cited by:
CitedKeyu and Others v Secretary of State for Foreign and Commonwealth Affairs and Another SC 25-Nov-2015
The Court was asked whether the respondents should be required to hold a public inquiry into a controversial series of events in 1948, when a Scots Guards patrol was alleged to shot and killed 24 unarmed civilians in a village called Batang Kali, in . .

Lists of cited by and citing cases may be incomplete.

Coroners, Human Rights

Updated: 11 November 2021; Ref: scu.439808

P, Regina (on The Application of) v HM Coroner for The District of Avon: CA 18 Dec 2009

The deceased was found hanging in her prison cell. The jury returned a verdict of accidental death, not being satisfied that she was not merely making a cry for help. The family appealed a finding that the inquest had satisfied the requirement for a fuller investigation of a death in custody, there having been an investigation and report by the Prisons’ Ombudsman. They said that the jury should have been advised that they could attach a narrative to their verdict. The deceased had given several signs of possible suicide, but these had not been put together.
Held: The jury had been given advice on completion of the form including the possibility of a narrative verdict. However, the direction gave the jury the impression that they could only attach a narrative if the verdict of suicide or accident was insufficient. That was, since Middleton, incorrect, a misdirection.
Nevertheless the verdict should not be quashed or a new inquest ordered. The presence of the Prisons ombudsman’s report, and the actions taken on it filled any lacunae in the satisfaction of the State’s article 2 obligations.

Dyson LJ, Maurice Kay LJ, Rimer LJ
[2009] EWCA Civ 1367
Bailii
European Convention on Human Rights 2, Coroners Act 1988 11(5)(b)(ii)
England and Wales
Citing:
Appeal fromP, Regina (On the Application of) v HM Coroner for the District Of Avon Admn 5-Mar-2009
The deceased was found suspended by a sheet in her prison cell. The jury found accidental death, not being satisfied that she was not issuing a cry for help. The family appealed saying that the jury had not been directed that they could provide a . .
CitedRegina 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, . .
CitedMiddleton, 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.
CitedRegina (Cash) v County of Northamptonshire Coroner Admn 2007
. .
CitedAmin, 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 . .

Lists of cited by and citing cases may be incomplete.

Coroners, Human Rights, Prisons

Updated: 11 November 2021; Ref: scu.384363

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. Hed: When section 13 is invoked a fresh inquest can only be ordered where it is ‘necessary or desirable in the interests of justice’. Those are critical words. It was not the statutory power which was relied upon, but judicial review. As to what verdict should be left to the jury ‘The strength of the evidence is not the only consideration and, in relation to wider issues, the coroner has a broader discretion. If it appears there are circumstances which, in a particular situation, mean in the judgment of the coroner, acting reasonably and fairly, it is not in the interest of justice that a particular verdict should be left to the jury, he need not leave that verdict. He, for example, need not leave all possible verdicts just because there is technically evidence to support them. It is sufficient if he leaves those verdicts which realistically reflect the thrust of the evidence as a whole.’ The galbraith guidelines shouldbe followed by a coroner when deciding whether to leave a particular verdict to the jury.
Lord Woolf MR: ‘The conclusion I have come to is that, so far as the evidence called before the jury is concerned, a coroner should adopt the Galbraith approach in deciding whether to leave a verdict. The strength of the evidence is not the only consideration and in relation to wider issues, the coroner has a broader discretion. If it appears there are circumstances which, in a particular situation, where in the judgment of the coroner, acting reasonably and fairly, it is not in the interest of justice that a particular verdict should be left to the jury, he need not leave that verdict. He, for example, need not leave all possible verdicts just because there is technically evidence to support them. It is sufficient if he leaves those verdicts which realistically reflect the thrust of the evidence as a whole. To leave all possible verdicts could in some situations merely confuse and overburden the jury and if that is the coroner’s conclusion he cannot be criticised if he does not leave a particular verdict’.
Hobhouse LJ: ‘I also endorse the need for legal directions to be given to juries in a clear and easily usable form. The use of written directions should be further considered in any case which is not wholly straightforward. There is scope for a body such as the Judicial Studies Board to be invited to prepare and provide sets of standard directions which coroners could use in such cases’.

Lord Woolf MR, Hobhouse LJ
[1998] EWCA Civ 101, [1999] 1 All ER 344
Bailii
England and Wales
Citing:
Appeal fromRegina v HM Coroner for Inner London (ex parte Lisa Douglas-Williams) Admn 31-Jul-1997
. .
CitedRegina 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 by:
CitedRegina 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 . .
CitedRegina (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 . .
CitedRegina (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 . .
See AlsoRegina 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 . .

Lists of cited by and citing cases may be incomplete.

Coroners

Leading Case

Updated: 09 November 2021; Ref: scu.143579

Pounder, Regina (on the Application of) v HM Coroner for the North and South Districts of Durham and Darlington and others: Admn 22 Jan 2009

The deceased died aged 14 in a Secure Training Centre by hanging. He had complained of his treatment and restraint methods used. The mother sought judicial review of the conduct of the inquest, wanting the coroner not to have ruled on the legality of the restraint methods used, and which of the STC Rules and the 1994 Act took precedence.
Held: The Rules were clear and the 1994 ACt could not be used to extend the powers of restraint. Not only was there no lawful authority to do any of this to Adam but doing this to him was subjecting him to at least degrading treatment contrary to Article 3 ECHR. The Coroner had put questions to the jury as to the appropriateness of the force used. The deceased had himself said that he wanted to challenge the legality of the force used, and ‘If Adam’s question had been answered by the Coroner or left open to the jury to consider with appropriate directions, the answers would have been clear. There was no right to hurt such a child in these circumstances. In my judgment it is fanciful to suppose that such an answer could have had no impact on the jury’s consideration of factors contributing to the death.’ The coroner should have considered whether the force used was legitimate. The inquest was quashed.

Blake J
[2009] EWHC 76 (Admin), [2009] 3 All ER 150
Bailii
Coroners Act 1988 8(1) 8(3) 11(5), Secure Training Centre Rules 1998 (SI 1998/472), Criminal Justice and Public Order Act 1994 9(3) 9(4)
England and Wales
Citing:
CitedAmin, 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 . .
CitedMiddleton, 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.
CitedHolgate-Mohammed v Duke HL 1984
A police officer had purported to arrest the plaintiff under the 1967 Act, suspecting her of theft. After interview she was released several hours later without charge. She sought damages alleging wrongful arrest. The judge had found that he had . .
CitedC, Regina (on the Application of) v Secretary of State for Justice CA 28-Jul-2008
The court was asked as to what methods of physical restraint were proper in institutions accommodating youths in custody.
Held: The Court had been wrong not to quash the amended rules on the grounds of procedural breaches. The amended rules . .
CitedAl-Nashif v Bulgaria ECHR 20-Jun-2002
Hudoc Judgment (Merits and just satisfaction) Preliminary objections dismissed (non-exhaustion, abuse of right of petition); Violation of Art. 5-4; Violation of Art. 8; Violation of Art. 13; Not necessary to . .

Lists of cited by and citing cases may be incomplete.

Coroners, Prisons, Human Rights

Updated: 09 November 2021; Ref: scu.280142

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 might engage Article 2 of the European Convention of Human Rights.
Held: The application succeeded. The respondent’s guidance misrepresented the position in law: ‘the essential thrust of the Guidance conveys to the typical caseworker that in every case where legal aid was sought the caseworker had to make an assessment (leading to a decision) of whether the state was arguably in breach of the underlying substantive obligation (whichever one it was) and that only if the conclusion was that there was such an arguable breach would the caseworker then proceed to decide whether on the facts of the case there was a need to give the next-of-kin legal aid. The Guidance, albeit that it is drafted at a high level, nonetheless purports to set out an accurate general description of the law. But in the absence of a clear recognition that there is a category of case where the investigative duty arises quite irrespective of the existence of arguable breach by the state the Guidance is materially misleading and inaccurate.’

Green J
[2015] EWHC 402 (Admin)
Bailii
European Convention on Human Rights 2, Legal Aid, Sentencing and Punishment of Offenders Act 2012 4 10
England and Wales
Citing:
CitedSmith, 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.
CitedKhan, 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 . .
CitedStephen Jordan (No 2) v The United Kingdom ECHR 10-Dec-2002
jordan_uk2ECHR2002
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 . .
CitedMiddleton, 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.
CitedGentle, 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 . .
CitedLegal Services Commission v Humberstone, Regina (On The Application of) CA 21-Dec-2010
Appeal against successful judicial review of refusal of legal aid for mother of deceased at inquest.
Held: ‘article 2 will be engaged in the much narrower range of cases where there is at least an arguable case that the state has been in . .

Lists of cited by and citing cases may be incomplete.

Legal Aid, Coroners, Human Rights

Updated: 02 November 2021; Ref: scu.543091

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 killing.
Held: If the trial had been in England, a coroner could not make a finding inconsistent with the trial verdict. The court emphasised the difficulty of this case: ‘The procedure at an inquest does not accord a would be defendant the safeguards that he would have in a criminal trial. There is no defendant and therefore no one upon whom the relevant burden of proof might lie. It is not fair that a person should risk the stigma of a finding of unlawful killing – even if the verdict technically conceals identity – without those safeguards and without the right to have deployed on his behalf the case that he was legally insane when he perpetrated the otherwise unlawful act. Crucially, we consider that the relevant direction which the coroner would have to give to a jury would be contorted and unsatisfactory.’ Insanity, properly raised, has to be disproved to the criminal standard to sustain a verdict of unlawful killing. The coroner had not adequately considered the father’s mental condition, and this court could not itself make that judgment. The case was remitted for further consideration.

Dobbs J
[2009] EWHC 854 (Admin), [2011] 1 QB 106, [2009] 4 All ER 1020, [2010] 2 WLR 1299
Bailii
Coroner’s Act 1988 11(5)(b)
England and Wales
Citing:
CitedRegina 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 . .
CitedRegina 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. . .
CitedRegina 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, . .
CitedDirector of Public Prosecutions v Newbury and Jones HL 12-May-1976
The two teenage defendants pushed a stone slab from a bridge onto an oncoming train. The slab went through the window and killed the guard. They appealed convictions for manslaughter.
Held: The appeals were dismissed. An unlawful act can found . .
CitedRegina v Larkin CCA 1943
There may be involuntary manslaughter, if the accused intentionally did an act which was unlawful and dangerous and that act inadvertently caused death. Humphreys J said: ‘Where the act which a person is engaged in performing is unlawful, then if at . .
CitedRegina v Lamb CA 1967
The defendant actor had shot his best friend when, in jest and without any intention of doing any harm or firing a bullet, he pulled the trigger of a revolver. There were no bullets opposite the barrel and he had not realised that the mechanism . .
CitedDaniel M’Naghten’s Case HL 1843
Daniel M’Naghten suffered from a mental disorder under which he believed that he was being persecuted by various bodies in authority, including the Tory Party. He sought to kill the Tory Prime Minister Sir Robert Peel, but shot and killed instead . .
CitedRegina 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 . .
CitedRegina v Sullivan HL 1984
The burden of establishing insanity in a criminal trial is on the defence on the balance of probabilities.
Lord Diplock said: ‘I agree with what was said by Devlin J. in Reg. v. Kemp (1957) 1 QB 399, 407, that ‘mind’ in the M’Naghten Rules is . .

Lists of cited by and citing cases may be incomplete.

Coroners, Crime

Updated: 02 November 2021; Ref: scu.341858

Maughan, Regina (on The Application of) v Her Majesty’s Senior Coroner for Oxfordshire: SC 13 Nov 2020

Standard of Proof for Narrative Verdict

‘This appeal arises out of the inquest held into the death of Mr James Maughan. It concerns the standard of proof, or degree of conclusivity, required for the determination of the result of an inquest into a death where the question is whether the deceased committed suicide. The result of an inquest may be given in a single short form conclusion (using simply the word suicide) and/or in a brief narrative statement (‘a narrative conclusion’). This appeal has to consider whether the degree of conclusivity is the same in both cases, and what it is.’

Lord Reed, President, Lord Kerr, Lord Wilson, Lord Carnwath, Lady Arden
[2020] UKSC 46, [2020] 3 WLR 1298
Bailii, Bailii Press Summary, Bailii Issues and Facts
Coroners and Justice 2009 Act, Coroners (Inquests) Rules 2013
England and Wales
Citing:
Appeal fromMaughan, Regina (on The Application of) v Her Majesty’s Senior Coroner for Oxfordshire CA 10-May-2019
Standard of Proof of Suicide at Inquest
Questions of importance concerning the law and practice of coroners’ inquests where an issue is raised as to whether the deceased died by suicide. The questions can be formulated as follows:
(1) Is the standard of proof to be applied the . .
At AdmnMaughan, Regina (on The Application of) v Senior Coroner for Oxfordshire Admn 26-Jul-2018
The court was asked whether a coroner or a coroner’s jury, after hearing the evidence at an inquest into a death, may lawfully record a conclusion to the effect that the deceased committed suicide reached on the balance of probabilities; or whether . .

Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 02 November 2021; Ref: scu.655658

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 AandE department. From there he escaped and jumped into and drowned in the Thames.
Held: The claim succeeded.
Sir Anthony Clarke MR said: ‘Article 2 is engaged in the sense that it gives rise to certain obligations on the part of the state whenever a person dies in circumstances which give reasonable grounds for thinking that the death may have resulted from a wrongful act of one of its agents. ‘The coroner accepted that the events at the hospital were relevant, but it was not clear how they could have been dismissed without a fuller enquiry.
As to the summoning of the jury: ‘The coroner has a duty to summon a jury under the subsection if it appears to him that the death occurred in circumstances the continuation or possible recurrence of which is prejudicial to the health or safety of the public (our emphasis). Quite apart from the precise language, the purpose of the provision seems to us to be to stop similar risks to the health and safety of the public in the future. If the coroner is satisfied that because of steps taken since the relevant events there is no such risk, we can see no reason why the coroner should summon a jury under section 8(3)(d). ‘ The inquest verdict would be set aside. The coroner should judge whether a jury was appropriate in the light of the circumstances prevailing.
Sir Anthony Clarke MR said: ‘We do not accept Mr Fitzgerald’s submission that the principles in the custody cases, which have been analysed in some detail in the Amin . . and Middleton . . cases, apply here because Mr Takoushis would have been detained if the hospital had been aware that he was about to leave the hospital. In our opinion there is an important difference between those who are detained by the state and those who are not. Mr Takoushis was not.’

Sir Anthony Clarke MR, Chadwick, Moore-Bick LJJ
[2006] 1 WLR 461, [2005] EWCA Civ 1440, Times 08-Dec-2005
Bailii
Coroners Act 1988 8(3)(d), European Convention on Human Rights 2
England and Wales
Citing:
CitedRegina v North Humberside and Scunthorpe Coroner ex parte Jamieson QBD 12-Jul-1993
northhumberside_jamiesonCA1993
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 . .
CitedMiddleton, 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.
CitedRegina 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 . .
CitedRegina 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 . .
CitedRegina v Inner West London Coroner Ex Parte Dallaglio, and Ex Parte Lockwood Croft CA 16-Jun-1994
A coroner’s comment that the deceased’s relative was ‘unhinged’ displayed a bias which was irreparable. ‘The description ‘apparent bias’ traditionally given to this head of bias is not entirely apt, for if despite the appearance of bias the court is . .
CitedErikson v Italy ECHR 26-Oct-1999
The court described part of the state’s obligation under article 2 as including ‘the obligation to establish an effective judicial system for establishing the cause of a death which occurs in hospital and any liability on the part of the medical . .
CitedPowell 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 . .
CitedSalman 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 . .
CitedRegina (Wright) v Secretary of State for the Home Department Admn 2001
A serving prisoner suffered a severe asthmatic attack in his cell and died. An inquest was held at which the family of the deceased were present, but unrepresented for want of legal aid. There was no inquiry into the quality of the medical treatment . .
CitedJordan 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 . .
CitedCalvelli 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 . .
CitedEdwards 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 . .
CitedAmin, 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 . .
CitedGoodson 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 . .
CitedSieminska 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 . .
Appeal fromTakoushis, 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 . .

Cited by:
CitedD, 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 . .
CitedCameron and others v Network Rail Infrastructure Ltd QBD 18-May-2006
The claimant sought damages from the defendant after the death of her father in the Potters Bar rail crash. The defendant applied for summary judgment saying that English law did not recognise a claim by a family member of a deceased save through . .
CitedGentle and Clarke, Regina (on the Application Of) v Prime Minister and others CA 12-Dec-2006
The claimants appealed refusal of a judicial review of the defendant’s decision to enter into the war in Iraq. The claimants were parents of troops who had died in the war. They said that the legal advice given to the government was incorrect.
CitedSavage v South Essex Partnership NHS Foundation Trust QBD 21-Dec-2006
The claimant’s daughter had died after walking out of a mental health ward and being knocked down. She sought damages alleging negligence and in infringement of her daughter’s right to life.
Held: Negligence amounting to a breach of the right . .
CitedK v Central and North West London Mental Health NHS Trust and Another QBD 30-May-2008
k_centralQBD2008
The claimant appealed against an order striking out his claim in negligence. He had leaped from a window in a suicide attempt. The accommodation was provided by the defendant whilst caring for him under the 1983 Act.
Held: The case should be . .
CitedMorrison v The Independent Police Complaints Commission and Others Admn 26-Oct-2009
The claimant made a complaint of a serious assault by the police, by the use of a Taser. The defendant had referred the complaint to the IPCC, who said that they should investigate it themselves. The claimant said that to accord with his human . .
CitedRabone 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 . .
CitedSmith, 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.
CitedBirks, Regina (On the Application of) v Commissioner of Police of the Metropolis Admn 25-Sep-2014
The claimant police officer sought judicial review of a decision to continue his suspension. He had been investigated and cleared after a death in custody. He sought to join the Church of England Ministry and was offered a post. He was re-assured . .
CitedTyrrell 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, Health

Leading Case

Updated: 02 November 2021; Ref: scu.235462

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.
Held: The SSD’s appeal succeeded. ‘jurisdiction’ within the meaning of Article 1 was essentially territorial but extended in exceptional circumstances requiring special justification to other bases of jurisdiction. A soldier on active duty overseas was not within the jurisdiction of the UK so as to allow the operation of the Convention. The proposition asserted was a novel one, and the court should not extend a State’s duties beyond existing Strasbourg jurisprudence.
If the Convention had applied, an article 2 level coroner’s inquest would still not always be required. Baroness Hale, Lord Mance and Lord Kerr dissented in part.
Lord Collins said the exceptions to the finding of jurisdiction recognised by the Strasbourg court had consisted of (i) territorial jurisdiction by a state over the territory of another contracting state; (ii) extensions of territorial jurisdiction by analogy and (iii) commonsense extensions of the notion of jurisdiction to fit cases which plainly should be within the scope of the ECHR. This case was none of them.
Lord Mance said: ‘However, it is our duty to give effect to the domestically enacted Convention rights, while taking account of Strasbourg jurisprudence, although caution is particularly apposite where Strasbourg has decided a case directly in point or, perhaps, where there are mixed messages in the existing Strasbourg case law and, as a result, a real judicial choice to be made there about the scope or application of the Convention.’
Lord Hope of Craighead said: ‘Some situations in which the procedural obligation is triggered are now well recognised. The suicide of an individual while in the custody of the state is the prime example. It has been extended to the case where a prisoner attempted to commit suicide while in custody and suffered brain damage . This is because it has been recognised that prisoners as a class present a particular risk of suicide and because those who have custody of them, as agents of the state, are or may be in some way implicated. A Middleton inquest is required in all these cases, because it is at least possible that the prison authorities failed to take the steps to protect the prisoner’s life that the substantive right requires. As Lord Rodger of Earlsferry said in L’s case . . suicide is in this respect like any other violent death in custody. The procedural obligation extends to prisoners as a class irrespective of the particular circumstances in which the death occurred. The fact that they are under the care and control of the authorities by whom they are held gives rise to an automatic obligation to investigate the circumstances. The same is true of suicides committed by others subject to compulsory detention by a public authority, such as patients suffering from mental illness who have been detained under the Mental Health Acts . . This approach has the merit of clarity. Everyone knows from the outset that the inquest in these cases must follow the guidance that was given in Middleton’
Lord Phillips of Worth Matravers stated the difference between a preliminary inquiry to establish whether an article 2 investigation was called for on the facts surrounding any death, and an article 2 investigation itself: ‘The duty to hold an article 2 investigation arises where there are grounds for suspecting that a death may involve breach by the State of one of the substantive obligations imposed by article 2. This raises the question of how the State is to identify that there are grounds for such suspicion. Any effective scheme for protecting the right to life must surely require a staged system of investigation of deaths, under which the first stage takes place automatically in relation to every death, whether or not there are grounds for suspecting that there is anything untoward about the death. Where the first stage shows that the death has not, or may not have, resulted from natural causes, there will be a requirement for a further stage or stages of the investigation. The requirement for an article 2 investigation will only arise if the preceding stage of the investigation discloses that there is a possibility that the State has not complied with a substantive article 2 obligation.’

Lord Phillips of Worth Matravers PSC, Lord Hope of Craighead DPSC, Lord Rodger of Earlsferry, Lord Walker of Gestingthorpe, Baroness Hale of Richmond, Lord Brown of Eaton-under-Heywood, Lord Mance, Lord Collins of Mapesbury, Lord Kerr of Tonaghmore
[2010] UKSC 29, [2010] WLR (D) 165, [2010] 3 WLR 223, [2010] 3 All ER 1067, [2011] 1 AC 1, [2010] Inquest LR 119, [2010] UKHRR 1020, [2010] HRLR 28, 29 BHRC 497
Bailii, WLRD, SC Summary, SC
Human Rights Act 1998, European Convention on Human Rights 1, Coroners and Justice Act 2009 5, Armed Forces Act 2006
England and Wales
Citing:
CitedIssa And Others v Turkey ECHR 16-Nov-2004
Accountability for violation of the Convention rights and freedoms of persons in another state stems from the fact that article 1 of the Convention cannot be interpreted so as to allow a state party to perpetrate violations of the Convention on the . .
CitedBui van Thanh v United Kingdom ECHR 12-Mar-1990
The applicant, one of the ‘Vietnamese Boat People’, complained of the acts of government official in Hong Kong.
Held: The UK government had not extended the Convention to Hong Kong and the application failed. . .
CitedDrozd and Janousek v France and Spain ECHR 26-Jun-1992
The applicants complained of the unfairness of their trial in Andorra (which the Court held it had no jurisdiction to investigate) and of their detention in France, which was not found to violate article 5.
Held: Member states are obliged to . .
Appeal FromSecretary of State for Defence v Smith, Regina (on the Application of) CA 18-May-2009
The soldier had died of heatstroke after exercises in Iraq. The Minister appealed against a finding that the circumstances of his death required an investigation compliant with Article 2 human rights, saying that he was not subject to such . .
At First InstanceSmith v The Assistant Deputy Coroner for Oxfordshire Admn 11-Apr-2008
The claimant’s son had died of hyperthermia whilst serving in the army in Iraq. The parties requested a new inquisition after the coroner had rules that human rights law did not apply to servicemen serving outside Europe. Reports had been prepared . .
CitedSecretary of State for Defence v Al-Skeini and others (The Redress Trust Intervening) HL 13-Jun-2007
Complaints were made as to the deaths of six Iraqi civilians which were the result of actions by a member or members of the British armed forces in Basra. One of them, Mr Baha Mousa, had died as a result of severe maltreatment in a prison occupied . .
CitedOcalan v Turkey ECHR 12-May-2005
(Grand Chamber) – The applicant had been detained in Kenya. He had allowed himself to be taken by Kenyan officials to Nairobi airport in the belief that he was free to leave for a destination of his choice, but they took him to an aircraft in which . .
CitedOcalan v Turkey ECHR 12-Mar-2003
The applicant had led Kurdish separatists training and leading a gang of armed terrorists. Warrants for his arrest had been taken out in Turkey. He had lived for many years in Syria but then sought political asylum in Greece, Russia and Italy, none . .
CitedLoizidou v Turkey ECHR 23-Mar-1995
(Preliminary objections) The ECHR considered the situation in northern Cyprus when it was asked as to Turkey’s preliminary objections to admissibility: ‘although Article 1 sets limits on the reach of the Convention, the concept of ‘jurisdiction’ . .
CitedAl Skeini and Others, Regina (on the Application of) v Secretary of State for Defence and Another Admn 14-Dec-2004
Several dependants of persons killed in Iraq by British troops claimed damages.
Held: The court considered extensively the scope and applicability of Article 1 duties. In general an English court would have no jurisdiction over deaths abroad . .
CitedLoizidou v Turkey (Merits) ECHR 18-Dec-1996
The court was asked whether Turkey was answerable under the Convention for its acts in Northern Cyprus.
Held: It was unnecessary to determine whether Turkey actually exercised detailed control over the policies and actions of the authorities . .
CitedLoizidou v Turkey (Article 50) ECHR 28-Jul-1998
Hudoc Judgment (Just satisfaction) Pecuniary damage – financial award; Non-pecuniary damage – financial award; Costs and expenses award – Convention proceedings; Costs and expenses – claim rejected (State) . .
CitedBankovic v Belgium ECHR 12-Dec-2001
(Grand Chamber) Air strikes were carried out by NATO forces against radio and television facilities in Belgrade on 23 April 1999. The claims of five of the applicants arose out of the deaths of relatives in this raid. The sixth claimed on his own . .
CitedGentle, 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 . .
CitedCarson and Others v The United Kingdom ECHR 16-Mar-2010
(Grand Chamber) The court ruled admissible claims against the United Kingdom by 13 persons entitled to British State pensions for violation of article 14 of the Convention in combination with article 1 of the First Protocol. All the claimants had . .
CitedX v United Kingdom ECHR 1979
(Commission) The claimant sought admission of her complaint that being employed by the European Commission and resident in Belgium she had lost her right to vote. She contrasted her position with that of members of the armed forces and members of . .
CitedStephens v Malta (No. 1) ECHR 21-Apr-2009
The applicant, a British subject, had been arrested and detained in Spain under an arrest warrant issued by a court in Malta, but without competence to do so. The Court considered the issue of jurisdiction under article 1, saying: ‘the question to . .
CitedRegina on the Application of B and others v Secretary of State for the Foreign and Commonwealth Office CA 18-Oct-2004
The applicant children had been detained in immigration camps in Australia. They escaped and sought refuge in the British High Commission in Melbourne and claimed diplomatic asylum. They claimed in damages after being returned to the authorities in . .
CitedCyprus v Turkey ECHR 26-May-1975
ECHR (Commission) Article 24 of the Convention : Case referred to the Commission by a Contracting Party.
(a) The applicant Government, as constituted at and since the time of lodging the present . .
CitedGentilhomme, Schaff-Benhadji et Zerouki v France ECHR 14-May-2002
(French Text) In 1962 France and Algeria had signed a statement of principle on cultural co-operation which provided inter alia for French children residing in Algeria, including those having dual French and Algerian nationality under French law, to . .
CitedRegina 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, . .
CitedMcCann and Others v The United Kingdom ECHR 6-Oct-1995
mccann_ukECHR1995
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 . .
CitedMiddleton, 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.
CitedIsayeva, Yusupova And Bazayeva v Russia ECHR 24-Feb-2005
ECHR Judgment (Merits and Just Satisfaction). The court considered the duties of a signatory state under article 2 when taking substantial military actions against insurgents. . .
CitedAl-Saadoon and Mufdhi v The United Kingdom ECHR 2-Mar-2009
The claimant Iraqi nationals complained of their long term detention by British forces in Iraq, and of their transfer to the Iraqi authorities for trial for murder.
Held: The transfer was a breach of the applicants’ rights. The Iraqis had . .
CitedSacker, 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 . .
CitedNachova and Others v Bulgaria ECHR 6-Jul-2005
Hudoc Judgment (Merits and just satisfaction) Preliminary objection rejected (estoppel) ; Violation of Art. 2 with regard to deaths ; Violation of Art. 2 with regard to lack of effective investigation ; Not . .
CitedHurst, 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 . .
CitedCaledonian Railway Co v Walker’s Trustees 1882
The court considered the extent of the duty to compensate for disturbance of a business when land was compulsorily purchased. Lord Selborne LC said: ‘The obstruction by the execution of the work, of a man’s direct access to his house or land, . .
CitedClose v Steel Company of Wales Ltd 1962
The pursuer sought damages after injury arising from the use of a tool for a purpose other than that for which it was intended to be used. Lord Denning quoted Sir Frederick Pollock to say: ‘Judicial authority belongs not to the exact words used in . .
CitedRamsahai And Others v The Netherlands ECHR 10-Nov-2005
(Grand Chamber) The police had shot someone suspected of stealing a scooter. The family complained that they had not been given full access to the documents seen by the enquiry into his death.
Held: In order to be ‘effective’ as this . .
CitedMedvedyev And Others v France ECHR 29-Mar-2010
(Grand Chamber) A Cambodian vessel, The Winner, trafficked drugs on the high seas (Cape Verde). It was detected and boarded by the French authorities, detaining the crew on board and took them on the vessel to France for trial. France was, but . .
CitedCalvin’s case 1606
Sir Edward Coke said: ‘If this alien becomes an enemy (as all alien friends may) then he is utterly disabled to maintain any action, or get anything within this realm.’ and ‘If a King comes to a kingdom by conquest, he may change and alter the laws . .
CitedAlcom Ltd v Republic of Colombia HL 1984
A bank account used to cover the day-to-day expenses of an Embassy, clearly served sovereign purposes and therefore was immune from enforcement measures. The Act of 1978 must be read against the background of customary international law current in . .
CitedBurmah Oil Company (Burma Trading) Limited v Lord Advocate HL 21-Apr-1964
The General Officer Commanding during the war of 1939 to 1945 ordered the appellants oil installations near Rangoon to be destroyed. The Japanese were advancing and the Government wished to deny them the resources. It was done on the day before the . .
CitedNissan v The Attorney General HL 11-Feb-1969
The plaintiff was a British subject with a hotel in Cyprus taken over by British troops on a peace-keeping mission. At first the men were there by agreement of the governments of Cyprus and the United Kingdom. Later they became part of a United . .
CitedJones v Ministry of Interior for the Kingdom of Saudi Arabia and others HL 14-Jun-2006
The claimants said that they had been tortured by Saudi police when arrested on false charges. They sought damages, and appealed against an order denying jurisdiction over the defendants. They said that the allegation of torture allowed an exception . .
CitedLittrell v Government of the United States of America and Another (No 2) CA 24-Nov-1993
The plaintiff claimed damages for personal injuries arising from medical treatment which he had received at a United States military hospital in the United Kingdom while a serving member of the United States Air Force.
Held: Section 16(2) . .
CitedBici and Bici v Ministry of Defence QBD 7-Apr-2004
Claimants sought damages for personal injuries incurred when, in Pristina, Kosovo and during a riot, British soldiers on a UN peacekeeping expedition fired on a car.
Held: The incidents occurred in the course of peace-keeping duties. It was . .
CitedHolland v Lampen-Wolfe HL 20-Jul-2000
The US established a base at Menwith Hill in Yorkshire, and provided educational services through its staff to staff families. The claimant a teacher employed at the base alleged that a report on her was defamatory. The defendant relied on state . .
CitedMulcahy v Ministry of Defence CA 21-Feb-1996
A soldier in the Artillery Regiment was serving in Saudi Arabia in the course of the Gulf war. He was injured when he was part of a team managing a Howitzer, which was firing live rounds into Iraq, and he was standing in front of the gun when it was . .
CitedEngel And Others v The Netherlands (1) ECHR 8-Jun-1976
engel_netherlandsECHR1976
The court was asked whether proceedings in a military court against soldiers for disciplinary offences involved criminal charges within the meaning of Article 6(1): ‘In this connection, it is first necessary to know whether the provision(s) defining . .
CitedSoering v The United Kingdom ECHR 7-Jul-1989
(Plenary Court) The applicant was held in prison in the UK, pending extradition to the US to face allegations of murder, for which he faced the risk of the death sentence, which would be unlawful in the UK. If extradited, a representation would be . .
CitedJordan 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 . .
CitedCarson and Others v The United Kingdom ECHR 4-Nov-2008
(Grand Chamber) Pensioners who had moved abroad complained that they had been excluded from the index-linked uprating of pensions given to pensioners living in England.
Held: This was not an infringement of their human rights. Differences in . .
CitedRegina v Special Adjudicator ex parte Ullah; Regina v Secretary of State for the Home Department HL 17-Jun-2004
The applicants had had their requests for asylum refused. They complained that if they were removed from the UK, their article 3 rights would be infringed. If they were returned to Pakistan or Vietnam they would be persecuted for their religious . .
CitedMarkovic and Others v Italy ECHR 14-Dec-2006
The applicants were relatives of persons who had been killed in the NATO air-raid on Belgrade in 1999. The raid was said to be an act of war in violation of international law. It had been launched from bases in Italy. The Corte de Cassazione had . .
CitedIlascu and Others v Moldova and Russia ECHR 8-Jul-2004
(Grand Chamber) The two contracting states disputed the status of secessionist territory in Moldova called the Moldovian Republic of Transdniestria, which had been set up in 1991-2 with the support of the Russian Federation. The question was whether . .
CitedLubbe (Suing As Administrator Of The Estate Of Rachel Jacoba Lubbe) and 4 Others v Cape plc and Related Appeals HL 22-Jun-2000
South African asbestosis victims suing in England submitted that to stay their proceedings in favour of the South African forum would violate their article 6 rights. A stay was refused on the non-Convention ground that, because of the lack of . .
CitedMenson 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 . .
CitedSalman 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 . .
CitedLondon and Quadrant Housing Trust v Weaver, Regina; Equality and Human Rights Commission intervening CA 18-Jun-2009
The Trust appealed against a finding that in terminating an assured tenancy transferred to it from a local authority, it had acted as a hybrid public authority and was subject to controls under the 1998 Act.
Held: (Rix LJ dissenting). The . .
CitedAssanidze v Georgia ECHR 8-Apr-2004
Hudoc Judgment (Merits and just satisfaction) Preliminary objection dismissed (non-exhaustion of domestic remedies) ; Violation of Art. 5-1 with regard to unlawfull detention ; Not necessary to examine Art. 5-1 . .
CitedErgi v Turkey ECHR 28-Jul-1998
A village girl was shot dead when she went out onto the veranda of her home after security forces had been engaged in an ambush of PKK members close to the village where she lived. Nobody asked her family about the circumstances of the shooting, and . .
CitedSavage 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 . .
CitedByrzykowski v Poland ECHR 27-Jun-2006
. .
CitedTakoushis, 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 . .
CitedAkdogdu v Turkey ECHR 18-Oct-2005
ECHR Judgment (Merits and Just Satisfaction) – No violation of Art. 2; Violation of Art. 3; Non-pecuniary damage – financial award; Costs and expenses partial award – domestic proceedings; Costs and expenses . .

Cited by:
CitedZagorski and Baze, Regina (on The Application of) v Secretary of State for Business, Innovation and Skills and Others Admn 29-Nov-2010
The claimants, in the US awaiting execution for murders, challenged the permitting by the defendant for export of the chemical Sodium Thipental which would be used for their execution. The respondent said that its use in general anaesthesia practice . .
CitedMcCaughey 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. . .
CitedSmith and Others v Ministry of Defence QBD 30-Jun-2011
Claims were made after the deaths of British troops on active service in Iraq. In one case the deaths were from detonations of improvised explosive devices, and on others as a result of friendly fire. It was said that there had been a foreseeable . .
CitedAmbrose v Harris, Procurator Fiscal, Oban, etc SC 6-Oct-2011
(Scotland) The appellant had variously been convicted in reliance on evidence gathered at different stages before arrest, but in each case without being informed of any right to see a solicitor. The court was asked, as a devolution issue, at what . .
CitedSmith and Others v The Ministry of Defence SC 19-Jun-2013
The claimants were PRs of men who had died or were severely injured on active duty in Iraq being variously fired at by mistake by other coalition forces, or dying in vehicles attacked by roadside bombs. Appeals were heard against a finding that the . .
CitedLong, Regina (on The Application of) v Secretary of State for Defence Admn 15-Jul-2014
The claimant’s son had been one of six soldiers of the Royal Military police to have been murdered by an armed mob attacking a police station in Iraq in 2003. The said that their deaths had not been properly or sufficiently investigated. The corone . .
CitedBirks, Regina (On the Application of) v Commissioner of Police of the Metropolis Admn 25-Sep-2014
The claimant police officer sought judicial review of a decision to continue his suspension. He had been investigated and cleared after a death in custody. He sought to join the Church of England Ministry and was offered a post. He was re-assured . .
CitedLetts, 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 . .
CitedKennedy v The Charity Commission SC 26-Mar-2014
The claimant journalist sought disclosure of papers acquired by the respondent in its conduct of enquiries into the charitable Mariam appeal. The Commission referred to an absolute exemption under section 32(2) of the 2000 Act, saying that the . .
CitedSandiford, Regina (on The Application of) v Secretary of State for Foreign and Commonwealth Affairs CA 22-May-2013
The appellant, a British national and European citizen was in prison in Bali convicted of a criminal charge for which she might face the death penalty. Having insufficient funds she sought legal assistance from the respondent for hr appeal, and now . .
CitedSandiford, Regina (on The Application of) v The Secretary of State for Foreign and Commonwealth Affairs SC 16-Jul-2014
The appellant a British Citizen awaited execution in Singapore after conviction on a drugs charge. The only way she might get legal help for a further appeal would be if she was given legal aid by the respondent. She sought assistance both on Human . .
CitedTyrrell 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 . .
CitedCommissioner 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.

Armed Forces, Human Rights, Coroners, Constitutional

Leading Case

Updated: 02 November 2021; Ref: scu.420019

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 when feelings are running high and the spectators are emotionally involved and vocal. Once again it should not be forgotten that an inquest is a fact finding exercise and not a method of apportioning guilt. The procedure and rules of evidence which are suitable for one are unsuitable for the other. In an inquest it should never be forgotten that there are no parties, there is no indictment, there is no prosecution, there is no defence, there is no trial, simply an attempt to establish facts. It is an inquisitorial process, a process of investigation quite unlike a criminal trial where the prosecutor accuses and the accused defends, the judge holding the balance or the reins whichever metaphor one chooses to use.’
and ‘the function of an inquest is to seek out and record as many of the facts concerning the death as [the] public interest requires.’ The Broderick Committee exhaustively considered the role of the coroner’s inquest in modern society. The committee identified the following grounds of public interest which they believed that a coroner’s inquiry should serve:
(1) To determine the medical cause of death;
(ii) To allay such rumours or suspicion;
(iii) to draw attention to the existence of circumstances which, if unremedied, might lead to further deaths;
To advance medical knowledge;
(v) To preserve the legal inteersts of the deceased person’s family, heirs or other interested parties.
However ‘It is not the function of the Coroner’s inquest to provide a forum for attempts to gather evidence for pending or future criminal or civil proceedings.”

Lord Lane CJ
[1982] 126 SJ 625
England and Wales
Cited by:
CitedIn 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 . .
CitedIn 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 . .
CitedAssistant 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 . .
CitedHurst, 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 . .
CitedO’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 . .
CitedWilkinson, Regina (on The Application of) v HM Coroner for The Greater Manchester South District Admn 11-Oct-2012
The court was asked whether evidence of the commission of the criminal offence of causing death by careless driving contrary to section 2B of the 1988 Act is capable of justifying a verdict of ‘unlawful killing’ at an inquest.
Held: The . .
ApprovedMcKerr v Armagh Coroner HL 1990
It is for the coroner to decide how to adduce the necessary evidence as to death. Lord Goff discussed Rule 17 of the 1980 Rules: ‘Nor, in my opinion, does the mere fact that a rule restricts the power of a coroner as to the evidence which he may . .
CitedSecretary of State for Foreign and Commonwealth Affairs v Assistant Deputy Coroner for Inner North London Admn 27-Jun-2013
The coroner was to hold an inquest into the death of Alexander Litvinenko, a prominent Russian exile. The Secretary of State issued a public interest immunity certificate in respect of several documents sought for the inquest, which, in part, the . .

Lists of cited by and citing cases may be incomplete.

Coroners

Leading Case

Updated: 01 November 2021; Ref: scu.187755

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, but the Coroner directed the jury not to return a verdict which included any reference to lack of care.
Held: A finding of neglect is rarely consistent with a suicide, or one where the deceased contributed to his own death. It would be wrong to allow the jury to attribute blame.
Sir Thomas Bingham MR said: ‘Despite the rulings given by the appellate courts, problems continue to arise both for coroners seeking to conduct inquests and direct juries in accordance with the law as they understand it and for those interested in the death of a deceased person seeking to explore the full circumstances of the death and draw lessons which may prevent repetition. Coroners do their utmost to confine the proceedings before them within the bounds of what they consider to be proper. Interested parties not infrequently strain to pursue their quarry well beyond the boundaries set by the coroner.’ and ‘General Conclusions. An inquest is a fact finding inquiry conducted by a coroner, with or without a jury, to establish reliable answers to four important but limited factual questions. The first of these relates to the identity of the deceased, the second to the place of his death, the third to the time of death. In most cases these questions are not hard to answer but in a minority of cases the answer may be problematical. The fourth question, and that to which evidence and inquiry are most often and most closely directed, relates to how the deceased came by his death. Rule 36 requires that the proceedings and evidence shall be directed solely to ascertaining these matters and forbid any expression of opinion on any other matter.
Both in section 11(5)(b)(ii) of the Act of 1988 and in rule 36(1)(b) of the Rules of 1984, ‘how’ is to be understood as meaning ‘by what means.’ It is noteworthy that the task is not to ascertain how the deceased died, which might reach general and far-reaching issues, but ‘how the deceased came by his death,’ a more limited question directed to the means by which the deceased came by his death. It is the duty of the coroner as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the relevant facts are fully, fairly and fearlessly investigated. He is bound to recognise the acute public concern rightly aroused where deaths occur in custody. He must ensure that the relevant facts are exposed to public scrutiny, particularly if there is evidence of foul play, abuse or inhumanity. He fails in his duty if his investigation is superficial, slipshod or perfunctory. But the responsibility is his. He must set the bounds of the inquiry. He must rule on the procedure to be followed. His decisions, like those of any other judicial officer, must be respected unless and until they are varied or overruled.’
‘It is not the function of a coroner or his jury to determine or appear to determine, any question of criminal or civil liability, to apportion guilt or attribute blame . . the prohibition on returning a verdict so as to appear to determine any question of civil liability is unqualified, applying whether anyone is named or not. Much of the difficulty to which verdicts of lack of care have given rise appear to be due to an almost inevitable confusion between this expression and the lack of care which is the foundation for a successful claim in common law negligence. Since many of those seeking that verdict do so as a stepping-stone towards such a claim the boundary is bound to become blurred. But lack of care in the context of an inquest has been correctly described as the obverse of self-neglect. It is to be hoped that in future the expression ‘lack of care’ may for practical purposes be deleted from the lexicon of inquests and replaced by ‘neglect’. Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide basic medical attention or shelter or warmth for someone in a dependent position (because of youth, age, illness or incarceration) who cannot provide it for himself. Failure to provide medical attention for a dependent person whose physical condition is such as to show he obviously needs it may amount to neglect . . Neglect can rarely, if ever, be an appropriate verdict on its own . . Neglect may contribute to a death from natural causes. Neither neglect nor self-neglect should ever form any part of any verdict unless a clear and direct causal connection is established between the conduct so described and the cause of death.’

Sir Thomas Bingham MR
Times 28-Apr-1994, Independent 27-Apr-1994, [1995] QB 1, [1994] 3 All ER 972, [1994] 3 WLR 82, (1994) 158 JP 1011;, (1994) 19 BMLR 35
Coroners Act 1988 11(5)(b)(ii), Coroners Rules 1984 36(1) 40
England and Wales
Citing:
Appeal fromRegina v North Humberside and Scunthorpe Coroner ex parte Jamieson QBD 12-Jul-1993
northhumberside_jamiesonCA1993
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 . .
CitedRegina 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 by:
CitedRegina (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 . .
CitedKhan, 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: . .
CitedRegina 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 . .
CitedIn 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 . .
CitedSacker, 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 . .
CitedIn 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 . .
CitedIn 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 . .
CitedBloom 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 . .
CitedLM, Re (Reporting Restrictions; Coroner’s Inquest) FD 1-Aug-2007
A child had died. In earlier civil proceedings, the court had laid responsibility with the mother. Restrictions had been placed on the information which would effectively prevent the coroner conducting his inquest. The coroner sought a lifting of . .
CitedO’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 . .
CitedP, Regina (on The Application of) v HM Coroner for The District of Avon CA 18-Dec-2009
The deceased was found hanging in her prison cell. The jury returned a verdict of accidental death, not being satisfied that she was not merely making a cry for help. The family appealed a finding that the inquest had satisfied the requirement for a . .
CitedJones v HM Coroner for The Southern District of Greater London and Another Admn 28-Apr-2010
The mother of the deceased asked for a new inquest, saying that there had been insufficient enquiry. He was an adult suffering Asperger’s syndrome and other difficulties, but had sought and been given excess prescriptions of fentanyl a drug to . .
CitedSmith, 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.
CitedWilkinson, Regina (on The Application of) v HM Coroner for The Greater Manchester South District Admn 11-Oct-2012
The court was asked whether evidence of the commission of the criminal offence of causing death by careless driving contrary to section 2B of the 1988 Act is capable of justifying a verdict of ‘unlawful killing’ at an inquest.
Held: The . .
CitedKent County Council, Regina (on The Application of) v HM Coroner for The County of Kent (North-West District) and Others Admn 15-Oct-2012
The council sought review of the coroner’s decision that the inquest would be an article 2 inquest and with a jury. The deceased was 14 years old and had taken methadone. In the months before his death, he had had involvement with the council’s . .
CitedSreedharan, 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 . .
CitedTyrrell 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, Health Professions, Prisons

Leading Case

Updated: 01 November 2021; Ref: scu.87444

Secretary of State for Defence v Smith, Regina (on the Application of): CA 18 May 2009

The soldier had died of heatstroke after exercises in Iraq. The Minister appealed against a finding that the circumstances of his death required an investigation compliant with Article 2 human rights, saying that he was not subject to such jurisdiction whilst not on a British base in Iraq. The deceased’s family argued that the jurisdiction was not merely geographical, but was also personal.
Held: Human rights law is focused on the status of the potential victim and his relationship with the state. ‘the right to life of a soldier in combat is different from that of a soldier not in combat, but the question here is whether there should be a distinction between the rights of a soldier at a base and when he leaves the base. The answer to that question is not in our view affected by the existence or application of the principle that his rights cannot be ‘divided or tailored’. The Minister’s appeal failed.

Sir Anthony Clarke MR, Keene LJ, Dyson LJ
[2009] EWCA Civ 441, [2009] 4 All ER 985, [2009] 3 WLR 1099, [2009] UKHRR 1139, 27 BHRC 89, [2009] ACD 54
Bailii, Times
European Convention on Human Rights 2
England and Wales
Citing:
CitedGentle, 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 . .
CitedSecretary of State for Defence v Al-Skeini and others (The Redress Trust Intervening) HL 13-Jun-2007
Complaints were made as to the deaths of six Iraqi civilians which were the result of actions by a member or members of the British armed forces in Basra. One of them, Mr Baha Mousa, had died as a result of severe maltreatment in a prison occupied . .
CitedBankovic v Belgium ECHR 12-Dec-2001
(Grand Chamber) Air strikes were carried out by NATO forces against radio and television facilities in Belgrade on 23 April 1999. The claims of five of the applicants arose out of the deaths of relatives in this raid. The sixth claimed on his own . .
CitedDrozd and Janousek v France and Spain ECHR 26-Jun-1992
The applicants complained of the unfairness of their trial in Andorra (which the Court held it had no jurisdiction to investigate) and of their detention in France, which was not found to violate article 5.
Held: Member states are obliged to . .
CitedSoering v The United Kingdom ECHR 7-Jul-1989
(Plenary Court) The applicant was held in prison in the UK, pending extradition to the US to face allegations of murder, for which he faced the risk of the death sentence, which would be unlawful in the UK. If extradited, a representation would be . .
CitedCyprus v Turkey ECHR 26-May-1975
ECHR (Commission) Article 24 of the Convention : Case referred to the Commission by a Contracting Party.
(a) The applicant Government, as constituted at and since the time of lodging the present . .
CitedAl-Saadoon and Another, Regina (on the Application of) v Secretary of State for Defence CA 21-Jan-2009
The claimants had been detained on the request of the Iraqi criminal court in a detention facility run by the UK armed forces. They complained of their proposed transfer to an Iraqi facility in anticipation of facing trial for murder, for which if . .
CitedEngel And Others v The Netherlands (1) ECHR 8-Jun-1976
engel_netherlandsECHR1976
The court was asked whether proceedings in a military court against soldiers for disciplinary offences involved criminal charges within the meaning of Article 6(1): ‘In this connection, it is first necessary to know whether the provision(s) defining . .
CitedIssa And Others v Turkey ECHR 16-Nov-2004
Accountability for violation of the Convention rights and freedoms of persons in another state stems from the fact that article 1 of the Convention cannot be interpreted so as to allow a state party to perpetrate violations of the Convention on the . .
CitedRegina v Special Adjudicator ex parte Ullah; Regina v Secretary of State for the Home Department HL 17-Jun-2004
The applicants had had their requests for asylum refused. They complained that if they were removed from the UK, their article 3 rights would be infringed. If they were returned to Pakistan or Vietnam they would be persecuted for their religious . .
Appeal fromSmith v The Assistant Deputy Coroner for Oxfordshire Admn 11-Apr-2008
The claimant’s son had died of hyperthermia whilst serving in the army in Iraq. The parties requested a new inquisition after the coroner had rules that human rights law did not apply to servicemen serving outside Europe. Reports had been prepared . .

Cited by:
Appeal FromSmith, 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.
Armed Forces, Human Rights, Coroners

Updated: 02 November 2021; Ref: scu.346156

Maughan, Regina (on The Application of) v Her Majesty’s Senior Coroner for Oxfordshire: CA 10 May 2019

Standard of Proof of Suicide at Inquest

Questions of importance concerning the law and practice of coroners’ inquests where an issue is raised as to whether the deceased died by suicide. The questions can be formulated as follows:
(1) Is the standard of proof to be applied the criminal standard (satisfied so as to be sure) or the civil standard (satisfied that it is more probable than not) in deciding whether the deceased deliberately took his own life intending to kill himself?
(2) Does the answer depend on whether the determination is expressed by way of short-form conclusion or by way of narrative conclusion?

Underhill, Davis, Nicola Davies LJJ
[2019] EWCA Civ 809, [2019] 3 All ER 567, [2019] 3 WLR 365, [2019] Med LR 325, [2019] QB 1218, [2019] WLR(D) 271
Bailii, WLRD
Suicide Act 1961 1, Human Rights Act 1998, Coroners and Justice Act 2009 5 7 10, Coroners (Inquests) Rules 2013 34
England and Wales
Citing:
At First InstanceMaughan, Regina (on The Application of) v Senior Coroner for Oxfordshire Admn 26-Jul-2018
The court was asked whether a coroner or a coroner’s jury, after hearing the evidence at an inquest into a death, may lawfully record a conclusion to the effect that the deceased committed suicide reached on the balance of probabilities; or whether . .

Cited by:
Appeal fromMaughan, Regina (on The Application of) v Her Majesty’s Senior Coroner for Oxfordshire SC 13-Nov-2020
Standard of Proof for Narrative Verdict
‘This appeal arises out of the inquest held into the death of Mr James Maughan. It concerns the standard of proof, or degree of conclusivity, required for the determination of the result of an inquest into a death where the question is whether the . .

Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 01 November 2021; Ref: scu.637324

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 appeal was dismissed. The right to an inquiry was procedural and depended first on the claimants establishing an arguable case that the substantive right was infringed. There would be no ability at common law to require such and inquiry, and no obligation was to be created through human rights law.
The issue was however justiciable. Baroness Hale said: ‘it is now common ground that if a Convention right requires the court to examine and adjudicate upon matters which were previously regarded as non-justiciable, then adjudicate we must.’
Lord Bingham of Cornhill observed: ‘issues which judicial tribunals have traditionally been very reluctant to entertain because they recognise their limitations as suitable bodies to resolve them. This is not to say that if the claimants have a legal right the courts cannot decide it. The defendants accept that if the claimants have a legal right it is justiciable in the courts, and they do not seek to demarcate areas into which the courts may not intrude.’

Lord Bingham of Cornhill, Lord Hoffmann, Lord Hope of Craighead, Lord Scott of Foscote, Lord Rodger of Earlsferry, Baroness Hale of Richmond, Lord Carswell, Lord Brown of Eaton-under-Heywood, Lord Mance
[2008] UKHL 20, Times 10-Apr-2008, [2008] 2 WLR 879, [2008] 1 AC 1356, [2008] UKHRR 822, [2008] HRLR 27, [2008] 3 All ER 1
Bailii, HL
European Convention on Human Rights 2 3
England and Wales
Citing:
CitedJordan 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 . .
CitedIn 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 . .
CitedEdwards 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 . .
CitedMiddleton, 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.
CitedSoering v The United Kingdom ECHR 7-Jul-1989
(Plenary Court) The applicant was held in prison in the UK, pending extradition to the US to face allegations of murder, for which he faced the risk of the death sentence, which would be unlawful in the UK. If extradited, a representation would be . .
CitedSecretary of State for Defence v Al-Skeini and others (The Redress Trust Intervening) HL 13-Jun-2007
Complaints were made as to the deaths of six Iraqi civilians which were the result of actions by a member or members of the British armed forces in Basra. One of them, Mr Baha Mousa, had died as a result of severe maltreatment in a prison occupied . .
CitedRegina v Jones (Margaret), Regina v Milling and others HL 29-Mar-2006
Domestic Offence requires Domestic Defence
Each defendant sought to raise by way of defence of their otherwise criminal actions, the fact that they were attempting to prevent the commission by the government of the crime of waging an aggressive war in Iraq, and that their acts were . .
At first instanceGentle 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 . .
Appeal fromRegina (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. . .
CitedButtes Gas and Oil Co v Hammer (No 3) HL 1981
In a defamation action, issues arose as to two conflicting oil concessions which neighbouring states in the Arabian Gulf had granted over their territorial and offshore waters. The foreign relations of the United Kingdom and Iran were also involved . .
CitedCouncil of Civil Service Unions v Minister for the Civil Service HL 22-Nov-1984
Exercise of Prerogative Power is Reviewable
The House considered an executive decision made pursuant to powers conferred by a prerogative order. The Minister had ordered employees at GCHQ not to be members of trades unions.
Held: The exercise of a prerogative power of a public nature . .
CitedRegina v Foreign Secretary ex parte Everett CA 20-Oct-1988
A decision taken under the royal prerogative whether or not to issue a passport was subject to judicial review, although relief was refused on the facts of the particular case.
Taylor LJ summarised the effect of the GCHQ case as making clear . .
CitedJH Rayner (Mincing Lane) Ltd v Department of Trade and Industry HL 1989
An undisclosed principal will not be permitted to claim to be party to a contract if this is contrary to the terms of the contract itself. Thus the provision in the standard form B contract of the London Metal Exchange ‘this contract is made between . .
CitedRegina (Abbasi) v Secretary of State for Foreign Affairs CA 6-Nov-2002
There is no authority in law to support the imposition of an enforceable duty on the state to protect the citizen, and although the court was able to intervene, in limited ways, in the way in which the Foreign and Commonwealth Office used its . .
CitedTakoushis, 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 . .
CitedRegina 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.
CitedCampaign for Nuclear Disarmament (CND) v Prime Minister and others Admn 17-Dec-2002
CND sought an advisory declaration as to the meaning of UN Security Council resolution 1441, which had given Iraq ‘a final opportunity to comply with its disarmament obligations’ and whether the resolution authorised states to take military action . .
CitedBubbins 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 . .
CitedEngel And Others v The Netherlands (1) ECHR 8-Jun-1976
engel_netherlandsECHR1976
The court was asked whether proceedings in a military court against soldiers for disciplinary offences involved criminal charges within the meaning of Article 6(1): ‘In this connection, it is first necessary to know whether the provision(s) defining . .
CitedTaylor v United Kingdom ECHR 1994
. .
CitedBanks v United Kingdom ECHR 6-Feb-2007
The applicants complained of maltreatment by prison officers in breach of article 3. The matter had been investigated by the Crown Prosecution Service which had decided not to prosecute. Civil proceedings had been raised and settled. The applicants . .
CitedScholes v Secretary of State for the Home Department CA 17-Oct-2006
The deceased had committed suicide whilst in prison. The judge had requested that prison should be told of the risk of self harm. The mother appealed refusal of the judge to grant a judicial review of the Home Secretary’s refusal to grant, as . .
CitedMcShane 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 . .
CitedGrigoriades v Greece ECHR 25-Nov-1997
Hudoc Judgment (Merits and just satisfaction) Violation of Art. 10; No violation of Art. 7; Non-pecuniary damage – finding of violation sufficient; Costs and expenses partial award – Convention proceedings . .
CitedMcBride v United Kingdom ECHR 2006
. .
CitedStott (Procurator Fiscal, Dunfermline) and Another v Brown PC 5-Dec-2000
The system under which the registered keeper of a vehicle was obliged to identify herself as the driver, and such admission was to be used subsequently as evidence against her on a charge of driving with excess alcohol, was not a breach of her right . .

Cited by:
CitedSmith v The Assistant Deputy Coroner for Oxfordshire Admn 11-Apr-2008
The claimant’s son had died of hyperthermia whilst serving in the army in Iraq. The parties requested a new inquisition after the coroner had rules that human rights law did not apply to servicemen serving outside Europe. Reports had been prepared . .
CitedCorner House Research and Others, Regina (on the Application of) v The Serious Fraud Office HL 30-Jul-2008
SFO Director’s decisions reviewable
The director succeeded on his appeal against an order declaring unlawful his decision to discontinue investigations into allegations of bribery. The Attorney-General had supervisory duties as to the exercise of the duties by the Director. It had . .
CitedSecretary of State for Defence v Smith, Regina (on the Application of) CA 18-May-2009
The soldier had died of heatstroke after exercises in Iraq. The Minister appealed against a finding that the circumstances of his death required an investigation compliant with Article 2 human rights, saying that he was not subject to such . .
CitedSmith, 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.
CitedSmith and Others v The Ministry of Defence SC 19-Jun-2013
The claimants were PRs of men who had died or were severely injured on active duty in Iraq being variously fired at by mistake by other coalition forces, or dying in vehicles attacked by roadside bombs. Appeals were heard against a finding that the . .
CitedLord Carlile of Berriew QC, and Others, Regina (on The Application of) v Secretary of State for The Home Department SC 12-Nov-2014
The claimant had supported the grant of a visa to a woman in order to speak to members of Parliament who was de facto leader of an Iranian organsation which had in the past supported terrorism and had been proscribed in the UK, but that proscription . .
CitedShergill and Others v Khaira and Others SC 11-Jun-2014
The parties disputed the trusts upon which three Gurdwaras (Sikh Temples) were held. The Court of Appeal had held that the issues underlying the dispute were to be found in matters of the faith of the Sikh parties, and had ordered a permanent stay. . .
CitedLetts, 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 . .
CitedTyrrell 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.

Armed Forces, Coroners, Human Rights

Leading Case

Updated: 01 November 2021; Ref: scu.266539

Hassan v The United Kingdom (GC): ECHR 16 Sep 2014

Grand Chamber – The applicant alleged that his brother was arrested and detained by British forces in Iraq and was subsequently found dead in unexplained circumstances. He complained under Article 5-1, 2, 3 and 4 of the Convention that the arrest and detention were arbitrary and unlawful and lacking in procedural safeguards and under Articles 2, 3 and 5 that the United Kingdom authorities failed to carry out an investigation into the circumstances of the detention, ill-treatment and death.
Held: ‘the powers of internment under the Third and Fourth Geneva Conventions, relied on by the Government as a permitted ground for the capture and detention of Tarek Hassan, are in direct conflict with Article 5 – 1 of the Convention. The Court does not have any legitimate tools at its disposal, as a court of law, to remedy this clash of norms. It must therefore give priority to the Convention, as its role is limited under Article 19 to ‘[ensuring] the observance of the engagements undertaken by the High Contracting Parties in the Convention and the Protocols thereto’. By attempting to reconcile the irreconcilable, the majority’s finding today does not, with respect, reflect an accurate understanding of the scope and substance of the fundamental right to liberty under the Convention, as reflected in its purpose and its historical origins in the atrocities of the international armed conflicts of the Second World War.’

Dean Spielmann, P
29750/09 – Grand Chamber Judgment, [2014] ECHR 936, [2014] ECHR 1162
Bailii, Bailii
European Convention on Human Rights
Human Rights

Human Rights, Coroners, Armed Forces, News

Updated: 01 November 2021; Ref: scu.536666

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 investigation, and the proposed amendment would leave in place the finding of unlawful killing. There was little to be served by further investigation of whether the deceased had given consent to non-therapeutic treatment. The court approved the proposal.

The Honourable Mr Justice David Clarke Lord Justice Richards
[2006] EWHC 309 (Admin)
Bailii
England and Wales
Citing:
CitedMowlem Plc, Regina (on the Application Of) v District of Avon HM Assistant Deputy Coroner and Another Admn 13-May-2005
The court has power to amend an inquisition by the substitution of words in an appropriate case. The power was only to be exercised with extreme caution: ‘The bottom line, so it seems to me, is that words can be thus substituted if they are words to . .
CitedLongfield 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, . .

Lists of cited by and citing cases may be incomplete.

Coroners

Leading Case

Updated: 01 November 2021; Ref: scu.238768

Jenkins, Regina (on The Application of) v HM Coroner for Portsmouth and South and Others: Admn 11 Dec 2009

The deceased had contracted gangrene, but not sought treatment, and he died of it. The claimant challenged the narrative verdict saying that it was perverse and that the only proper verdict was unlawful killing by his partner, a nurse who had provided some nursing care. The deceased had spiritual beliefs regarding natural healing, and was found to have refused medical assistance.
Held: Had there been a finding that the deceased had lost his capacity before his death, then the partner would have found herself under an obligation to seek treatment. There had been no such finding and the coroner had considered it a a possibility. The claimant had not shown the verdict to be perverse.

Pitchford J
[2009] EWHC 3229 (Admin)
Bailii
England and Wales
Citing:
CitedRegina v Stone and Dobinson CACD 1977
The male defendant, Stone, and his mentally disabled son lived in Stone’s house with the female defendant, Dobinson. Stone’s sister came to live as a lodger. She neglected herself to such an extent that she became helplessly infirm. Fanny refused to . .
CitedLand v Land; In re Land, deceased ChD 13-Jul-2006
The claimant had cared for his elderly mother who ‘shunned any type of ‘officialdom’ including doctors and home helps.’ However, the claimant so neglected her that she suffered severe bed sores which had become infected in consequence of her lying . .
CitedIn Re T (Adult: Refusal of Treatment) CA 30-Jul-1992
Appeal with regard to a right as to how the claimant should live. . .
CitedRegina v Hood CACD 2004
The defendant had been convicted of the manslaughter by gross negligence of his wife. On 14 March 2002 she had suffered a fall at home fracturing a number of bones including her right leg and hip. The defendant sought no medical help until 4 April . .
CitedHE v Hospital NHS Trust and Another FD 7-May-2003
Munby J gave reasons for his decision to permit AE’s treating doctors to infuse her with blood, if necessary, notwithstanding the existence of a living will in which she refused, in advance, to accept the transfusion of blood. He said: ‘There is now . .

Lists of cited by and citing cases may be incomplete.

Coroners, Health Professions

Updated: 01 November 2021; Ref: scu.384053

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 to asking whether the coroner’s decision on the resumption should have been affected by any duty of the state to enquire as to the cause of the death. It was not clear that no responsibility could attach to the police. The attack was of the sort which the deceased had feared and for which he had sought help. There were real doubts that even an inquest could provide the sort of enquiry required under human rights law since the jury would be restricted in the verdicts it could return. The coroner’s appeal succeeded. (Lord Mance and Baroness Hale dissenting)
Lord Brown of Eaton-under-Heywood said that the interpretative effect that Community law required was strictly confined to those case where, on their particular facts, the application of the domestic legislation in its ordinary meaning would produce a result incompatible with the relevant European Community legislation: ‘In cases where no European Community rights would be infringed, the domestic legislation is to be construed and applied in the ordinary way.’

Lord Bingham of Cornhill, Lord Rodger of Earlsferry, Baroness Hale of Richmond, Lord Brown of Eaton-under-Heywood, Lord Mance
[2007] UKHL 13, [2007] 2 WLR 726, [2007] 2 All ER 1025, [2007] 2 AC 189
Bailii
Coroners Act 1988 16(3), Human Rights Act 1998
England and Wales
Citing:
CitedRegina v North Humberside and Scunthorpe Coroner ex parte Jamieson QBD 12-Jul-1993
northhumberside_jamiesonCA1993
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 . .
CitedMiddleton, 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.
CitedEmpress Car Company (Abertillery) Ltd v National Rivers Authority HL 22-Jan-1998
A diesel tank was in a yard which drained into a river. It was surrounded by a bund to contain spillage, but that protection was over ridden by an extension pipe from the tank to a drum outside the bund. Someone opened a tap on that pipe so that . .
CitedIn re McKerr CANI 10-Jan-2003
The appellant’s son and two others had been shot dead by police officers. There remained considerable controversy over the circumstances. The matter had been taken to the ECHR which had found the enquiry inadequate. The parties now disputed the . .
CitedCommissioner of Police for the Metropolis v Reeves (Joint Administratix of The Estate of Martin Lynch, Deceased) HL 11-Feb-1999
The deceased was a prisoner known to be at risk of committing suicide. Whilst in police custody he hanged himself in his prison cell. The Commissioner accepted that he was in breach of his duty of care to the deceased, but not that that breach was . .
CitedRegina 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 . .
CitedRegina 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 . .
CitedWilson v Secretary of State for Trade and Industry; Wilson v First County Trust Ltd (No 2) HL 10-Jul-2003
The respondent appealed against a finding that the provision which made a loan agreement completely invalid for lack of compliance with the 1974 Act was itself invalid under the Human Rights Act since it deprived the respondent of its property . .
Appeal fromHurst 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 . .
CitedRegina v Inner West London Coroner Ex Parte Dallaglio, and Ex Parte Lockwood Croft CA 16-Jun-1994
A coroner’s comment that the deceased’s relative was ‘unhinged’ displayed a bias which was irreparable. ‘The description ‘apparent bias’ traditionally given to this head of bias is not entirely apt, for if despite the appearance of bias the court is . .
CitedOsman 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, . .
CitedRegina v Walthamstow Coroner, Ex parte Rubenstein 19-Feb-1982
The 1988 Act was a consolidating Act. . .
CitedRegina v Secretary of State for Transport, Ex parte Factortame Ltd HL 18-May-1989
The applicants were companies owned largely by Spanish nationals operating fishing vessels within UK waters. The 1988 Act required them to re-register the vessels as British fishing vessels. The sought suspension of enforcement pending a reference . .
CitedMarleasing SA v La Comercial Internacional de Alimentacion SA ECJ 13-Nov-1990
Sympathetic construction of national legislation
LMA OVIEDO sought a declaration that the contracts setting up Commercial International were void (a nullity) since they had been drawn up in order to defraud creditors. Commercial International relied on an EC . .
CitedPearson 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 . .
CitedGhaidan v Godin-Mendoza HL 21-Jun-2004
Same Sex Partner Entitled to tenancy Succession
The protected tenant had died. His same-sex partner sought a statutory inheritance of the tenancy.
Held: His appeal succeeded. The Fitzpatrick case referred to the position before the 1998 Act: ‘Discriminatory law undermines the rule of law . .
CitedImperial Chemical Industries v Colmer ECJ 16-Jul-1998
A member state was not allowed to impose a tax regime which discriminated against the subsidiaries of a company based in that state where they were based in other member states, but discrimination was allowed where the subsidiaries were based . .
CitedImperial Chemical Industries v Colmer ECJ 16-Jul-1998
A member state was not allowed to impose a tax regime which discriminated against the subsidiaries of a company based in that state where they were based in other member states, but discrimination was allowed where the subsidiaries were based . .
CitedRegina 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.
CitedGingi v The Secretary of State for Work and Pensions CA 14-Nov-2001
It is possible that in some circumstances the same enactment may be construed differently according to whether it applies in circumstances covered by a directive. Arden LJ approved the following passage from Bennion: ‘It is legitimate for the . .
CitedRegina v Secretary of State for the Home Department ex parte Brind HL 7-Feb-1991
The Home Secretary had issued directives to the BBC and IBA prohibiting the broadcasting of speech by representatives of proscribed terrorist organisations. The applicant journalists challenged the legality of the directives on the ground that they . .
CitedRegina v Chief Immigration Officer, Heathrow Airport, Ex parte Salamat Bibi CA 1976
Lord Denning MR said that: ‘Treaties and declarations do not become part of our law until they are made law by Parliament’.
Iin relation to the application of broad Convention principles in the context of immigration powers, he said: ‘I . .
CitedFernandes v Secretary of State CA 1981
Article 8 of the Convention was relied upon by the appellant to resists his return.
Held: The Secretary of State in exercising his statutory powers was not obliged to take into account the provisions of the Convention, it not being part of the . .
CitedCREEDNZ Inc v The Governor General 1981
(New Zealand) The court looked at those considerations which a decision maker can choose for himself whether or not to take them into account. Cooke J said: ‘what has to be emphasised is that it is only when the statute expressly or impliedly . .
CitedIn Re Findlay, in re Hogben HL 1985
A public authority, and the Prison Service in particular, is free, within the limits of rationality, to decide on any policy as to how to exercise its discretions; it is entitled to change its policy from time to time for the future, and a person . .
CitedChundawadra v Immigration Appeal Tribunal CA 1988
Ratification of the European Convention on Human Rights did not create a justiciable legitimate expectation that the Convention’s provisions would be complied with. Slade LJ said there was no evidence of ‘any relevant express promise or regular . .
CitedRegina v Secretary of State for the Environment, Ex parte NALGO CA 1992
Neill LJ explained article 8 of the Convention in the light of Brind: ‘(1) Article 10 is not part of English domestic law. It is therefore not necessary for the Minister when exercising an administrative decision conferred on him by Parliament to . .
CitedRantzen v Mirror Group Newspapers (1986) Ltd and Others CA 1-Apr-1993
Four articles in the People all covered the same story about Esther Rantzen’s organisation, Childline, suggesting that the plaintiff had protected a teacher who had revealed to Childline abuses of children occurring at a school where he taught, by . .
CitedBolton Metropolitan Borough Council and Others v Secretary of State for Environment and Others CA 4-Aug-1994
A decision maker can take a preliminary view of a matter provided that he continues to keep an open mind. . .
CitedBolton Metropolitan District Council and Others v Secretary of State for the Environment and Others HL 25-May-1995
There had been an application in 1986 for planning permission for a shopping centre in Trafford. There were two public enquiries, followed, as public policy changed by further representations. The plaintiff complained that the eventual decision . .
CitedMcCann and Others v The United Kingdom ECHR 6-Oct-1995
mccann_ukECHR1995
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 . .
CitedRegina 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 . .
CitedTakoushis, 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 . .
CitedRegina (Smeaton) v Secretary of State for Health and Others Admn 18-Apr-2002
The claimant challenged the Order as regards the prescription of the morning-after pill, asserting that the pill would cause miscarriages, and that therefore the use would be an offence under the 1861 Act.
Held: ‘SPUC’s case is that any . .
CitedA 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 by:
CitedSmith, 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.
CitedMcCaughey 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. . .
CitedParkwood Leisure Ltd v Alemo-Herron and Others SC 15-Jun-2011
The claimants had been employed by a local authority and then transferred to the respondents. They had had the benefit that their terms of employment were subject to collective agreement. The respondent was not part of the negotiation of later . .
CitedANS and Another v ML SC 11-Jul-2012
The mother opposed adoption proceedings, and argued that the provision in the 2007 Act, allowing a court to dispense with her consent, infringed her rights under Article 8 and was therefore made outwith the powers of the Scottish Parliament.
CitedNHS Manchester v Fecitt and Others CA 25-Oct-2011
The appellant challenged reversal by the EAT of a finding that it had not unlawfully victimised the respondents for the making of a protected disclosure. The claimant had reported a co-worker exaggerating his qualifications. After repeated . .

Lists of cited by and citing cases may be incomplete.

Police, Coroners, Human Rights

Leading Case

Updated: 01 November 2021; Ref: scu.251022

Jones v HM Coroner for The Southern District of Greater London and Another: Admn 28 Apr 2010

The mother of the deceased asked for a new inquest, saying that there had been insufficient enquiry. He was an adult suffering Asperger’s syndrome and other difficulties, but had sought and been given excess prescriptions of fentanyl a drug to control bowel pain. The coroner had been unable to find an explanation for how he had been able to build up high concentrations of the drug when he had used only slow release patches. Warnings as to the dangers of the excess use of the patches came to light after the inquest.
Held: Another inquest should take place: ‘The defendant identified the central question, namely how the deceased came to have such a high concentration of fentanyl in his blood, but failed to investigate the answer to it, apparently on the basis that it could not be answered, save by making the assumption that the deceased had somehow come into possession of an additional supply of fentanyl transdermal patches from some other and unknown source. But as was forcefully submitted on behalf of the claimant, there was no evidential basis for such an assumption.’ In the light of the new evidence available as to the use of the drug, there was also a proper wider and public interest in an exploration of the issues raised.

Owen J, Toulson LJ
[2010] EWHC 931 (Admin), [2010] Inquest LR 80
Bailii
Coroners Act 1988 13
England and Wales
Citing:
CitedBloom 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 . .
CitedRegina v HM Coroner, Lincoln, ex parte Hay 19-Feb-1987
. .
CitedRegina 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, . .
CitedRegina v Inner West London Coroner Ex Parte Dallaglio, and Ex Parte Lockwood Croft CA 16-Jun-1994
A coroner’s comment that the deceased’s relative was ‘unhinged’ displayed a bias which was irreparable. ‘The description ‘apparent bias’ traditionally given to this head of bias is not entirely apt, for if despite the appearance of bias the court is . .
CitedMiddleton, 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.
CitedHM Coroner for the Eastern District of London, Regina (On the Application of) v Sutovic Admn 31-Jul-2009
The deceased had died in Serbia, but was buried in Acton. A second inquest had been ordered on the request of the respondent, and an exhumation licence granted for the purposes of a second post mortem examination. The respondent had refused her . .

Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 01 November 2021; Ref: scu.408663

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 the wrong alarm code in, and did not attempt to cut him down.
Held: The appeal failed. Though the rules permitted a Coroner to ask such a question, they did not impose a duty to so, and given the report submitted it was now unnecessary.
In this case the coroner had allowed a breach of rule 43. ‘The want of equipment, training and effective procedure which the undisputed evidence revealed was so eloquent of action that needed to be taken to prevent similar fatalities that the coroner cannot have believed otherwise (and, to be fair to him, has nowhere suggested that he did believe otherwise). In such a situation the permissive power – ‘may report’ – could only be properly exercised in one way if the purposes of article 2 were to be respected, and that was by making a report on the issue.’
The division of duties between coroner and jury adequately protected the need under human rights law for a full investigation of a death in custody.

Lord Justice Sedley, Lord Justice Rimer and Lord Justice Etherton
[2009] EWCA Civ 1403, Times 11-Jan-2010
Bailii
Coroners Rules 1984 (SI 1984 No 552) 43
England and Wales
Citing:
Appeal FromLewis, 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
. .
CitedOneryildiz 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 . .
CitedSacker, 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 . .
CitedAllen, Regina (On the Application of) v Coroner for Inner North London CA 25-Jun-2009
. .
CitedMiddleton, 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.
Coroners, Human Rights

Leading Case

Updated: 01 November 2021; Ref: scu.392510

Regina v West Yorkshire Coroner ex parte Smith: CA 2 Jan 1982

The applicant challenged the refusal of the coroner to hold an inquest into the death of his daughter in Rhodesia.
Held: Coroners in England and Wales are under a duty to investigate a death which occurred overseas if both the body is returned to the coroner’s district and the circumstances are such that an investigation would have been conducted if the death had occurred in England and Wales. Donaldson LJ said that Parliament could have added a rider that if the death occurred abroad other than on the high seas, the coroner need not or even should not enquire into the cause of death. The words of this section were clearly and wholly free from ambiguity. He continued: ‘Once it is appreciated that it is the dead body lying within the jurisdiction which gives rise to the need for inquiry and which is the subject of the inquiry, the section is free from any possible objection that it creates what the Americans call a ‘long arm jurisdiction’.
and ‘The presence of a dead body in this country is a factor of significance. It creates a very real and legitimate public interest in holding an inquiry, and this interest is no way extra-territorial. In the absence of a death certificate by an appropriate authority in this country, it may well be considered essential at the very least to ascertain where the body came from, whether the deceased died in this country and, if so, how. The public interest centres upon the body which is in this country, upon the cause of death of that body and only incidentally upon where that cause or the death itself occurred.’
and ‘Inevitably a coroner conducting an inquisition into a death abroad will be faced with difficulties of evidence and so on, but that must have been so ever since the statute of George II . . Coroners are well experienced [in] dealing with such problems.’

Donaldson LJ
[1982] 3 WLR 920, [1982] 126 SJ 728, [1982] 3 All ER 1098
Coroners Act 1887 3(1) 7(1)
England and Wales
Citing:
Appeal fromRegina v West Yorkshire Coroner ex parte Smith QBD 1982
The applicant’s daughter had died in Kenya. Her body was returned to England and he sought an inquest.
Held: The court did not have jurisdiction to hold an inquest. . .

Cited by:
CitedShafi 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

Leading Case

Updated: 01 November 2021; Ref: scu.254559

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.
Held: The jury should indeed have been given opportunity to explain their verdict: ‘By one means or another the jury should, to meet the procedural obligation in article 2, have been permitted to express their conclusion on the central facts explored before them’, but private communications between the coroner and the jury were inappropriate. In order for these rules to meet the state’s procedural investigative duty under Article 2 of the Convention the word ‘how’ in sub-rule (1)(b) of the Coroner’s Rules should now be interpreted not simply to mean ‘by what means’, as earlier cases had held, but also to include ‘and in what circumstances.’
The House considered the article 2 duties of a member state: ‘The European Court of Human Rights has repeatedly interpreted article 2 of the European Convention as imposing on member states substantive obligations not to take life without justification and also to establish a framework of laws, precautions, procedures and means of enforcement which will, to the greatest extent reasonably practicable, protect life.
The European Court has also interpreted article 2 as imposing on member states a procedural obligation to initiate an effective public investigation by an independent official body into any death occurring in circumstances in which it appears that one or other of the foregoing substantive obligations has been, or may have been, violated and it appears that agents of the state are, or may be, in some way implicated.’
Lord Bingham of Cornhill said: ‘However the jury’s factual conclusion is conveyed, rule 42 should not be infringed. Thus there must be no finding of criminal liability on the part of a named person. Nor must the verdict appear to determine any question of civil liability. Acts or omissions may be recorded, but expressions suggestive of civil liability, in particular ‘neglect’ or ‘carelessness’ and related expressions, should be avoided.’

Lord Bingham of Cornhill, Lord Hope of Craighead, Lord Walker of Gestingthorpe, Baroness Hale of Richmond and Lord Carswell
[2004] UKHL 10, Times 12-Mar-2004, [2004] 2 AC 182, [2004] 2 WLR 800, [2004] UKHRR 501, [2004] 2 All ER 465, (2004) 79 BMLR 51, [2004] Lloyds Rep Med 288, [2004] 17 BHRC 49, (2004) 168 JPN 479, (2004) 168 JP 329
Bailii, House of Lords
Coroners Act 1988, European Convention on Human Rights 2, Coroners Rules 36
England and Wales
Citing:
Appeal fromRegina (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 . .
CitedLCB v The United Kingdom ECHR 9-Jun-1998
The court had no jurisdiction to consider allegations not raised before the commission or predating a country’s accession to the convention. There was no breach in a failure to record an exposure to radiation in a test. Article 2 imposes substantive . .
CitedOsman 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, . .
CitedOneryildiz 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 . .
CitedPowell 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 . .
CitedEdwards 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 . .
CitedCalvelli 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 . .
CitedKeenan 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 . .
CitedTaylor v United Kingdom ECHR 1994
. .
CitedMcCann and Others v The United Kingdom ECHR 6-Oct-1995
mccann_ukECHR1995
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 . .
CitedSalman 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 . .
CitedMastromatteo 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 . .
CitedEdwards 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 . .
CitedSieminska 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 . .
CitedJordan 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 . .
CitedRegina v Walthamstow Coroner, Ex parte Rubenstein 19-Feb-1982
The 1988 Act was a consolidating Act. . .
CitedRegina v HM Coroner for Birmingham, Ex parte Secretary of State for the Home Department 1990
. .
CitedRegina 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 . .
Appeal fromRegina (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 . .
CitedMiddleton, 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 . .
CitedIn 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 by:
CitedIn 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 . .
Appealed toRegina (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 . .
CitedSacker, 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 . .
CitedThree Rivers District Council and others v Governor and Company of the Bank of England (No 6) HL 11-Nov-2004
The Bank anticipated criticism in an ad hoc enquiry which was called to investigate its handling of a matter involving the claimant. The claimant sought disclosure of the documents created when the solicitors advised employees of the Bank in . .
CitedRegina (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 . .
CitedD, 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 . .
CitedPlymouth 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 . .
CitedTakoushis, 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 . .
AppliedLongfield 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, . .
CitedTakoushis, 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 . .
CitedD, 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 . .
CitedParkin 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 . .
CitedBloom 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 . .
CitedCameron and others v Network Rail Infrastructure Ltd QBD 18-May-2006
The claimant sought damages from the defendant after the death of her father in the Potters Bar rail crash. The defendant applied for summary judgment saying that English law did not recognise a claim by a family member of a deceased save through . .
CitedScholes, 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 . .
CitedGentle and Clarke, Regina (on the Application Of) v Prime Minister and others CA 12-Dec-2006
The claimants appealed refusal of a judicial review of the defendant’s decision to enter into the war in Iraq. The claimants were parents of troops who had died in the war. They said that the legal advice given to the government was incorrect.
CitedGentle, 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 . .
CitedWarren, Regina (on the Application of) v Her Majesty’s Assistant Coroner for Northamptonshire Admn 29-Apr-2008
The deceased had committed suicide in his prison cell. Prison officers were charged with manslaughter by gross neglect, but they were discharged. The applicant sought now to challenge the refusal of the coroner to allow to be called to give evidence . .
CitedHurst, 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 . .
CitedSmith v The Assistant Deputy Coroner for Oxfordshire Admn 11-Apr-2008
The claimant’s son had died of hyperthermia whilst serving in the army in Iraq. The parties requested a new inquisition after the coroner had rules that human rights law did not apply to servicemen serving outside Europe. Reports had been prepared . .
CitedSavage 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 . .
CitedPounder, Regina (on the Application of) v HM Coroner for the North and South Districts of Durham and Darlington and others Admn 22-Jan-2009
The deceased died aged 14 in a Secure Training Centre by hanging. He had complained of his treatment and restraint methods used. The mother sought judicial review of the conduct of the inquest, wanting the coroner not to have ruled on the legality . .
CitedAl-Sweady and Others, Regina (on the Application of) v Secretary of State for the Defence Admn 2-Oct-2009
The claimant’s son had died whilst in the custody of the British Armed Forces in Iraq. His uncle now claimed that his human rights had been infringed. The case ‘raised a fundamental issue of jurisdiction under Article 1 of the ECHR because if the . .
CitedP, Regina (on The Application of) v HM Coroner for The District of Avon CA 18-Dec-2009
The deceased was found hanging in her prison cell. The jury returned a verdict of accidental death, not being satisfied that she was not merely making a cry for help. The family appealed a finding that the inquest had satisfied the requirement for a . .
CitedLewis, 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 . .
CitedJones v HM Coroner for The Southern District of Greater London and Another Admn 28-Apr-2010
The mother of the deceased asked for a new inquest, saying that there had been insufficient enquiry. He was an adult suffering Asperger’s syndrome and other difficulties, but had sought and been given excess prescriptions of fentanyl a drug to . .
CitedSmith, 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.
CitedWilkinson, Regina (on The Application of) v HM Coroner for The Greater Manchester South District Admn 11-Oct-2012
The court was asked whether evidence of the commission of the criminal offence of causing death by careless driving contrary to section 2B of the 1988 Act is capable of justifying a verdict of ‘unlawful killing’ at an inquest.
Held: The . .
CitedKent County Council, Regina (on The Application of) v HM Coroner for The County of Kent (North-West District) and Others Admn 15-Oct-2012
The council sought review of the coroner’s decision that the inquest would be an article 2 inquest and with a jury. The deceased was 14 years old and had taken methadone. In the months before his death, he had had involvement with the council’s . .
CitedBirks, Regina (On the Application of) v Commissioner of Police of the Metropolis Admn 25-Sep-2014
The claimant police officer sought judicial review of a decision to continue his suspension. He had been investigated and cleared after a death in custody. He sought to join the Church of England Ministry and was offered a post. He was re-assured . .
CitedLetts, 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 . .
CitedTyrrell 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, Prisons, Human Rights

Leading Case

Updated: 01 November 2021; Ref: scu.194438

Wilkinson, Regina (on The Application of) v HM Coroner for The Greater Manchester South District: Admn 11 Oct 2012

The court was asked whether evidence of the commission of the criminal offence of causing death by careless driving contrary to section 2B of the 1988 Act is capable of justifying a verdict of ‘unlawful killing’ at an inquest.
Held: The coroner had been wrong to leave the offences of causing death by dangerous driving and causing death by careless driving to the jury as possible bases for a verdict of unlawful killing. Causing death by careless or inconsiderate driving should not be treated as ‘unlawful killing’ for the purposes of the conclusion of an inquest whatever conclusion may be reached in other contexts. The essence of the inquest is solely to identify the deceased, and how, when and where doied, and the particulars required for registration purposes. It should not seek determination of any issue of civil or criminal liability. The verdict of unlawful killing was available to distinguish between cases where of an accident of some kind even with some blame, and cases where it would be an abuse of language to describe the events leading to death as simply an accident.

Foskett J, Peter Thornton QC
[2012] EWHC 2755 (Admin), [2012] WLR(D) 274
Bailii, WLRD
Road Traffic Act 1988 2B, Articles of Eyre 1194, Coroners Act 1988, Coroners Rules 1984 42
England and Wales
Citing:
CitedRegina 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 . .
CitedRegina v Government of Holloway Prison, Ex parte Jennings HL 1983
J sought habeas corpus to avoid her extradition to California on a charge of manslaughter arising from a motor accident. Her counsel argued that the unlawful killing of another by the reckless driving of a motor vehicle on a road was no longer . .
CitedRegina 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, . .
CitedAppleby, Regina v (Attorney-General’s Reference (No 60 of 2009) CACD 18-Dec-2009
Each defendant had been convicted of an assault resulting in a death, but where no weapon had been used and where but for the death the charge would have been assault occasioning actual bodily harm.
Held: The decision in Furby, while still . .
CitedMiddleton, 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.
Coroners, Road Traffic

Updated: 01 November 2021; Ref: scu.464820

Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson: QBD 12 Jul 1993

northhumberside_jamiesonCA1993

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 leave a lack of care verdict to the jury where a doctor had taken the decision which led to the death, in a case of suicide of a prisoner. He could do so despite the statutory prohibition on any verdict being framed in such a way as to appear to determine any question of liability.
Sir Thomas Bingham MR set out the coroner’s duty: ‘It is the duty of the Coroner, as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the relevant facts are fully, fairly and fearlessly investigated. .’ The court gave guidance on directions to be given by coroners on the lack of care verdict: ‘It is not the function of a coroner or his jury to determine or appear to determine, any question of criminal or civil liability, to apportion guilt or attribute blame . . the prohibition on returning a verdict so as to appear to determine any question of civil liability is unqualified, applying whether anyone is named or not. Much of the difficulty to which verdicts of lack of care have given rise appear to be due to an almost inevitable confusion between this expression and the lack of care which is the foundation for a successful claim in common law negligence . . it is to be hoped that in future the expression ‘lack of care’ may for practical purposes be deleted from the lexicon of inquests and replaced by ‘neglect’. Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide basic medical attention or shelter or warmth for someone in a dependent position (because of youth, age, illness or incarceration) who cannot provide it for himself. Failure to provide medical attention for a dependent person whose physical condition is such as to show he obviously needs it may amount to neglect . . Neglect can rarely, if ever, be an appropriate verdict on its own . . Neglect may contribute to a death from natural causes. Neither neglect nor self-neglect should ever form any part of any verdict unless a clear and direct causal connection is established between the conduct so described and the cause of death.’

Times 23-Jul-1993, Ind Summary 18-Oct-1993, Ind Summary 06-Sep-1993, Guardian 12-Jul-1993
Coroners Act 1988
Cited by:
Appeal fromRegina 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, . .
CitedO’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 . .
CitedTakoushis, 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 . .
CitedIn 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 . .
CitedParkin 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 . .
CitedAssistant 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 . .
CitedRegina v Davis HL 18-Jun-2008
The defendant had been tried for the murder of two men by shooting them at a party. He was identified as the murderer by three witnesses who had been permitted to give evidence anonymously, from behind screens, because they had refused, out of fear, . .
CitedHurst, 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, Prisons

Leading Case

Updated: 01 November 2021; Ref: scu.87445

HM Coroner for the Eastern District of London, Regina (On the Application of) v Sutovic: Admn 31 Jul 2009

The deceased had died in Serbia, but was buried in Acton. A second inquest had been ordered on the request of the respondent, and an exhumation licence granted for the purposes of a second post mortem examination. The respondent had refused her consent to an exhumation, and the Secretary of State did not confirm the order. The Coroner now challenged that decision.
Held: The Secretary of state’s decision was made on the basis of a long standing policy. The change of mind in the respondent was unfortunate for the claimant but it had been based on conscience. The refusal of a new licence was not irrational.

Tugendhat J, Laws LJ
[2009] EWHC 1974 (Admin)
Bailii
Burial Act 1857 25
England and Wales
Citing:
CitedRex v Saunders 1719
. .
See AlsoSutovic, 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: . .
CitedReed v Madon ChD 1989
The existence of exclusive rights of burial gives the owner of a body a right which is to be equated with a right of property, interference with which is actionable
Morritt J described an exclusive right of burial arising under the 1847 Act as . .

Cited by:
CitedJones v HM Coroner for The Southern District of Greater London and Another Admn 28-Apr-2010
The mother of the deceased asked for a new inquest, saying that there had been insufficient enquiry. He was an adult suffering Asperger’s syndrome and other difficulties, but had sought and been given excess prescriptions of fentanyl a drug to . .

Lists of cited by and citing cases may be incomplete.

Coroners, Wills and Probate

Updated: 31 October 2021; Ref: scu.368619

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 circumstances of the deaths had not been subject to cross examination.
Held: The right to life is the most fundamental of human rights, and no derogation is to be allowed outside times of war. Where the circumstances of a death are exclusively within the power of the authorities, the burden of proof could be regarded as falling on the authorities. The right could be infringed by a failure to investigate such deaths properly. The inadequacies were such as to lead the court to conclude that that the right to life had been infringed. ‘there must be a sufficient element of public scrutiny of the investigation or its results to secure accountability in practice as well as in theory. The degree of public scrutiny required may well vary from case to case. In all cases, however, the next-of-kin of the victim must be involved in the procedure to the extent necessary to safeguard his or her legitimate interests.’

Times 18-May-2001, 24746/94, 37715/97, 30054/96, [2001] 11 BHRC 1, [2001] 37 EHRR 52, 28883/95, (2002) 34 EHRR 20, [2001] ECHR 323, [2001] ECHR 324, [2001] ECHR 325, [2001] ECHR 327, [2001] ECHR 328, [2001] ECHR 329, [2001] ECHR 330
Worldlii, Worldlii, Worldlii, Bailii, Bailii, Bailii, Bailii
European Convention on Human Rights 2
Human Rights
Citing:
See alsoIn 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 by:
CitedRegina (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 . .
CitedKhan, 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 . .
CitedAmin, 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 . .
CitedRegina (Wright) v Secretary of State for the Home Department Admn 2001
A serving prisoner suffered a severe asthmatic attack in his cell and died. An inquest was held at which the family of the deceased were present, but unrepresented for want of legal aid. There was no inquiry into the quality of the medical treatment . .
See AlsoIn 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 . .
CitedMiddleton, 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.
CitedMullen, Regina (on the Application of) v Secretary of State for the Home Department HL 29-Apr-2004
The claimant had been imprisoned, but his conviction was later overturned. He had been a victim of a gross abuse of executive power. The British authorities had acted in breach of international law and had been guilty of ‘a blatant and extremely . .
CitedThree Rivers District Council and others v Governor and Company of the Bank of England (No 6) HL 11-Nov-2004
The Bank anticipated criticism in an ad hoc enquiry which was called to investigate its handling of a matter involving the claimant. The claimant sought disclosure of the documents created when the solicitors advised employees of the Bank in . .
CitedRegina v Parole Board ex parte Smith, Regina v Parole Board ex parte West (Conjoined Appeals) HL 27-Jan-2005
Each defendant challenged the way he had been treated on revocation of his parole licence, saying he should have been given the opportunity to make oral representations.
Held: The prisoners’ appeals were allowed.
Lord Bingham stated: . .
CitedD, 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 . .
CitedTakoushis, 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 . .
CitedD, 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 . .
CitedGentle, 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 . .
CitedSmith v The Assistant Deputy Coroner for Oxfordshire Admn 11-Apr-2008
The claimant’s son had died of hyperthermia whilst serving in the army in Iraq. The parties requested a new inquisition after the coroner had rules that human rights law did not apply to servicemen serving outside Europe. Reports had been prepared . .
CitedJL, 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 . .
CitedMorrison v The Independent Police Complaints Commission and Others Admn 26-Oct-2009
The claimant made a complaint of a serious assault by the police, by the use of a Taser. The defendant had referred the complaint to the IPCC, who said that they should investigate it themselves. The claimant said that to accord with his human . .
See AlsoMcKerr v United Kingdom; Action of the Security Forces in Northern Ireland ECHR 17-Apr-2009
. .
CitedSmith, 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.
CitedSG and Others, Regina (on The Application of) v Secretary of State for Work and Pensions SC 18-Mar-2015
The court was asked whether it was lawful for the Secretary of State to make subordinate legislation imposing a cap on the amount of welfare benefits which can be received by claimants in non-working households, equivalent to the net median earnings . .
CitedTyrrell 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.

Human Rights, Coroners, Armed Forces

Leading Case

Updated: 31 October 2021; Ref: scu.166103

Finucane, Re Judicial Review: QBNI 23 Apr 2013

Application by Geraldine Finucane for discovery of documents in the course of a judicial review application brought by her in which she challenges the decision of the then Secretary of State for Northern Ireland to hold ‘a review into the death of Patrick Finucane (her husband) rather than a public inquiry of the kind recommended by Judge Peter Cory.’
Stephens J
[2013] NIQB 45
Bailii
Northern Ireland

Updated: 27 October 2021; Ref: scu.503538

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 gram-negative septicemia where bacillae had infected the blood stream. The coroner saw nothing in the reports to indicate that anything less than approriate treatment was provided for a rare but critical condition.
Held: ‘Section 13 contains a freestanding power to order a new inquest ‘where . . the discovery of new facts or evidence or otherwise [makes it] necessary or desirable in the interests of justice.’ There was now evidence to show that death was not inevitable from the condition described. ‘The family, in such cases, are entitled to a full inquiry into how and why the death occurred. ‘ They had not had that enquiry, and a new inquest was ordered.
Tuckey LJ, Field J
[2004] EWHC 3071 (Admin)
Bailii
Coroners Act 1988 13
England and Wales
Citing:
CitedRegina 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, . .
CitedMiddleton, 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.
CitedIn 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 . .
CitedO’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 by:
CitedJones v HM Coroner for The Southern District of Greater London and Another Admn 28-Apr-2010
The mother of the deceased asked for a new inquest, saying that there had been insufficient enquiry. He was an adult suffering Asperger’s syndrome and other difficulties, but had sought and been given excess prescriptions of fentanyl a drug to . .

Lists of cited by and citing cases may be incomplete.
Updated: 25 October 2021; Ref: scu.226918

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 coroner had been in error to direct the jury as to what must have been in the minds of the officers.
Leveson J
[2005] EWHC 857 (Admin)
Bailii
Coroners’ Act 1988
England and Wales
Citing:
CitedRegina 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 by:
CitedBennett, 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.
Updated: 16 October 2021; Ref: scu.224850

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 contended on behalf of the Chief Constable that there was no evidence of neglect to be left to the jury.
Held: The court rejected that submission, but concluded that the interest of justice did require second inquest: ‘(1) the coroners explanation of what constituted ‘neglect’ was erroneous. He began with a correct definition. Unfortunately he then amplified that definition in terms which suggested that simple negligence would suffice . . . (2) The coroner failed to give any direction in relation to causation . . . the jury must be satisfied that there was a clear and direct causal connection between the gross failure or failures by the police and the cause of death.’
Jackson J
[1999] 164 JP 191
England and Wales
Cited by:
CitedRegina 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.
Updated: 27 September 2021; Ref: scu.187757

Inquiry Into the Death of Mohammed Tasleen Iqbal: ScSf 20 Sep 2001

The matter concerned the death of a trainee diver. The court refused to make some of the recommendations requested, about the need for regulation of diving schools, as going beyond the scope of a fatal accident enquiry. The court restricted its formal findings and recommendations to the circumstances immediately attendant upon the death.
[2001] ScotSC 18
Bailii
Diving at Work Regulations 1997 (SI 1997 No 2776)
Scotland

Updated: 17 September 2021; Ref: scu.166526

Davies, Regina (on the Application of) v HM Deputy Coroner for Birmingham and Another: Admn 11 Feb 2003

[2003] EWHC 618 (Admin)
Bailii
England and Wales
Citing:
Appealed toRegina on the Application Of Christine Davies v HM Deputy Coroner for Birmingham CA 2-Dec-2003
. .

Cited by:
Appeal fromRegina on the Application Of Christine Davies v HM Deputy Coroner for Birmingham CA 2-Dec-2003
. .

Lists of cited by and citing cases may be incomplete.
Updated: 12 September 2021; Ref: scu.184966

Regina v HM Attorney-General for Northern Ireland and Another Ex Parte Devine, Same Ex Parte Breslin: HL 1 Apr 1992

The Coroner had held an inquest into the deaths of three persons who had been shot by soldiers. The Coroner had admitted statements made by the soldiers under Rule 17 of the Northern Ireland Rules. Those statements had been produced in evidence by the officers who had taken the statements. The statements of witnesses were admitted at an inquest despite the fact that the evidence was not compellable.
Held: Since under common law, the statements could be produced by the witnesses who were called, the application for judicial review was dismissed.
Lord Goff said: ‘The function of rule 17, which was first introduced in the Rules of 1963, is to regulate the circumstances in which a coroner in Northern Ireland may simply admit a document in evidence, without requiring the maker of the document to attend the inquest and give oral evidence. If the document is admitted as such in evidence under the rule, the contents of the document can no doubt be treated as evidence in the same way as the evidence of the maker of the document given orally to the like effect would have been so treated. In the absence of rule 17 there would, so far as I am aware, have been nothing to restrict the power of the coroner (who in the conduct of an inquisition has historically not been bound by the strict rules of evidence applicable in litigation: see Rex v Divine, ex part Walton [1930] w KB 29, 36, per Talbot J) to admit a document in evidence in t his way. It was for this reason that, in McKerr v Armagh Coroner [1990] 1 WLR 649, 657-658, I referred to rule 17 (as substituted by amendment in 1980) as an example of a rule of practice or procedure which restricts the power of a coroner, and described the rule as one which defines the power of a coroner to admit documentary evidence.
But, in agreement with both Carswell J and the Court of Appeal, I cannot see that rule 17 has the effect of excluding evidence which may otherwise be admissible, even it it is in documentary form. In particular, I cannot see that the rule excludes the power of a coroner to admit hearsay evidence otherwise proved simply because such evidence has been reduced to documentary form. The evidence in the present case consists of statements made by soldiers A, B and C to police officers, which were proved to have been so given by the police officers in question. Had these statements not been recorded in writing, rule 17 would obviously have been irrelevant, and it would have been open to the coroner to admit the statements in evidence, although the evidence was in such circumstances hearsay. As it was, the statements were recorded in writing; but it would be absurd that this fact should render such evidence inadmissible. I cannot see that rule 17, even on the assumption that the written statements were not admissible simply as documentary evidence under the rule, has the effect of excluding the statements as proved by the police officers in the present case. On this basis, the conclusion of the courts below on the admissibility of the evidence is, in my opinion, fully supportable.’
Lord Goff
Gazette 01-Apr-1992, [1992] 1 WLR 262
Coroners (Practice and Procedure) Rules (NI) 1980 17
Northern Ireland
Citing:
Appeal fromRegina v HM Attorney-General for Northern Ireland and Another Ex Parte Devine CANI 1992
An inquest was held into three deaths thought to be at the hands of British soldiers. The coroner had admitted written evidence from statements taken by British officers on the basis that the makers of the statements were not compellable as . .
Adhered toMcKerr v Armagh Coroner HL 1990
It is for the coroner to decide how to adduce the necessary evidence as to death. Lord Goff discussed Rule 17 of the 1980 Rules: ‘Nor, in my opinion, does the mere fact that a rule restricts the power of a coroner as to the evidence which he may . .

Cited by:
CitedIn 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 . .
CitedAssistant 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 . .
CitedRegina v Davis HL 18-Jun-2008
The defendant had been tried for the murder of two men by shooting them at a party. He was identified as the murderer by three witnesses who had been permitted to give evidence anonymously, from behind screens, because they had refused, out of fear, . .

Lists of cited by and citing cases may be incomplete.
Updated: 24 August 2021; Ref: scu.86862

Keyu and Others v Secretary of State for Foreign and Commonwealth Affairs and Another: SC 25 Nov 2015

The Court was asked whether the respondents should be required to hold a public inquiry into a controversial series of events in 1948, when a Scots Guards patrol was alleged to shot and killed 24 unarmed civilians in a village called Batang Kali, in Selangor.
Held: A requirement for a public or other inquiry was not imposed. (Baroness Hale of Richmond DPSC dissenting).
In the case of a death before the date on which the relevant state contracted to the Convention, two criteria must be satisfied before the article 2 investigation duty can arise, namely (i) relevant ‘acts or omissions’ after the critical date, and (ii) a ‘genuine connection’ between the death and the critical date. However the second criterion may be finessed where it is necessary to underpin ‘the underlying values of the Convention’. The evens had taken place before the Convention and there was no supervening event to create any obligation after the Convention came into effect. Customary International law had not developed to impose such an obligation, and even if it had, that could not be incorporated into our common law so as to displace clear statute obligations.
The Court considered the incorporation of customary international law into our own law: ‘Even if this conclusion turned out to be wrong, and it is now a principle of customary international law that a state must investigate deaths such as the Killings, even though they occurred as long ago as 1948, it would not be right to incorporate that principle into the common law. Parliament has expressly provided for investigations into deaths (i) through the coroners’ courts in the Coroners and Justices Act 2009, and its predecessors, and (ii) through inquiries in the 2005 Act, and its subject-specific predecessor statutes. It has also effectively legislated in relation to investigations into suspicious deaths through the incorporation of article 2 in the 1998 Act. In those circumstances, it appears to be quite inappropriate for the courts to take it onto themselves, through the guise of developing the common law, to impose a further duty to hold an inquiry, particularly when it would be a duty which has such potentially wide and uncertain ramifications, given that it would appear to apply to deaths which had occurred many decades – even possibly centuries – ago.’
An inquiry into the proportionality of a decision should not be confused with a full merits review: ‘a review based on proportionality is not one in which the reviewer substitutes his or her opinion for that of the decision-maker. At its heart, proportionality review requires of the person or agency that seeks to defend a decision that they show that it was proportionate to meet the aim that it professes to achieve. It does not demand that the decision-maker bring the reviewer to the point of conviction that theirs was the right decision in any absolute sense.’
Lord Neuberger, President, Lady Hale, Deputy President, Lord Mance, Lord Kerr, Lord Hughes
[2015] UKSC 69, [2016] AC 1355, [2015] 3 WLR 1665, [2015] WLR(D) 487, 40 BHRC 228, [2016] HRLR 2, UKSC 2014/0203
Bailii, WLRD, Bailii Summary, SC, SC Summary
European Convention on Human Rights 2, Inquiries Act 2005 1, Human Rights Act 1998, Coroners and Justices Act 2009
England and Wales
Citing:
CitedIn 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 . .
At first instanceKeyu and Others v Secretary of State for Foreign and Commonwealth Affairs and Another Admn 4-Sep-2012
It was said that a squad of the British army had caused the deaths of 24 civilians in 1948 in Batang Kali (now part of Malaysia.
Held: No inquiry was required. It was a matter of discretion, and there were no sustainable reasons for . .
Appeal fromKeyu and Others v Secretary of State for Foreign and Commonwealth Affairs and Another CA 19-Mar-2014
In 1948, there had been an incident in what later became part of Malaysia, in a counter insurgency patrol, when 24 civilians were said to have been killed by a patrol from the Scots Guards. The claimant now appealed against the refusal of a further . .
CitedMcCaughey 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. . .
CitedSilih v Slovenia ECHR 9-Apr-2009
(Grand Chamber) Article 2 imposes, in certain circumstances, a freestanding obligation in relation to the investigation of a death which applied even where the death itself had occurred before the member state ratified the Convention.: ”The court . .
CitedJanowiec And Others v Russia ECHR 21-Oct-2013
ECHR Grand Chamber – Article 3
Inhuman treatment
Positive obligations
Alleged failure adequately to account for fate of Polish prisoners executed by Soviet secret police at Katyn in 1940: no . .
CitedBlecic v Croatia ECHR 8-Mar-2006
The applicant alleged that her rights to respect for her home and to peaceful enjoyment of her possessions had been violated on account of the termination of her specially protected tenancy.
Held: Ratione temporis, the court had had no . .
CitedBrecknell v The United Kingdom ECHR 27-Nov-2007
Allegations had been made about police collusion with killings in Northern Ireland.
Held: Where there was credible information as to a possible perpetrator of an unlawful killing, there was a duty to investigate that evidence. Here the . .
CitedVarnava And Others v Turkey ECHR 18-Sep-2009
(Grand Chamber0 Turkey had failed to investigate the disappearance of individuals in Northern Cyprus in 1974. Turkey had ratified the Convention in 1954, but had only recognised the right of petition in 1987.
Held: (Grand Chamber) ‘the court . .
CitedHalide Cakir And Others v Cyprus ECHR 29-Apr-2010
Admissibility. It was said of the events in Cyprus in 1974 there had been a failure by the state to investigate unlawful killings. The court repeated the Grand Chamber’s formulation of the relevant law in Silih and Varnava, and then pointed out that . .
CitedAntonio Gutierrez Dorado and Carmen Dorado Ortiz v Spain ECHR 27-Mar-2012
. .
CitedJelic v Croatia ECHR 12-Jun-2014
ECHR Article 2-1
Effective investigation
Prosecution of officer with command responsibility, but not of direct perpetrators of killing: violation
Facts – In November 1991 the applicant’s . .

Cited by:
CitedAl Rabbat v Westminster Magistrates’ Court Admn 31-Jul-2017
The claimant appealed against refusal of an application for judicial review in turn of a refusal to allow private prosecutions of Tony Blair, Jack Straw and Lord Goldsmith in respect of their involvement in the war in Iraq, and the alleged crime of . .
CitedYoussef v Secretary of State for Foreign and Commonwealth Affairs SC 27-Jan-2016
An Egyptian national, had lived here since 1994. He challenged a decision by the Secretary of State,as a member of the committee of the United Nations Security Council, known as the Resolution 1267 Committee or Sanctions Committee. The committee . .
CitedPoshteh v Royal Borough of Kensington and Chelsea SC 10-May-2017
The appellant, applying for housing as a homeless person, had rejected the final property offered on the basis that its resemblance to the conditions of incarceration in Iran, from which she had fled, would continue and indeed the mental . .
CitedMichalak v General Medical Council and Others SC 1-Nov-2017
Dr M had successfully challenged her dismissal and recovered damages for unfair dismissal and race discrimination. In the interim, Her employer HA had reported the dismissal to the respondent who continued their proceedings despite the decision in . .
CitedBashir and Others, Regina (on The Application of) v Secretary of State for The Home Department SC 30-Jul-2018
(Interim Judgment) The respondent asylum seekers had been rescued in the Mediterranean and taken to an RAF base in Akrotiri on Cyprus, a sovereign base area. The court was now asked whether they were entitled, or should be permitted, to be resettled . .

Lists of cited by and citing cases may be incomplete.
Updated: 17 August 2021; Ref: scu.554900

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 and that duty prevails over any inhibition against appearing to determine questions of criminal or civil liability . . Secondly, the cases establish that although the is word ‘how’ is to be widely interpreted, it means ‘by what means’ rather than ‘in what broad circumstances’ . . In short the inquiry must focus on matters directly causative of death and must indeed, be confined to these matters alone (save for ascertainment of the other specific details mentioned in r36(1)). The recent, 11th edition of Jervis on Coroners puts it like this: ‘The question of how the deceased came by his death is of course wider than merely finding the principal cause of death, and it is therefore right and proper that the coroner should inquire into acts and omissions which are directly responsible for the death.’ and ‘The duty to inquire ‘how’ the deceased dies does not to my mind properly encompass inquiry also into the underlying responsibility for every circumstance which may be said to have contributed to the death.’
‘It is the duty of the coroner as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the facts are fully, fairly and fearlessly investigated. He is bound to recognise the acute public concern rightly aroused when deaths occur in custody. He must ensure that the relevant facts are exposed to public scrutiny, particularly if there is evidence of foul play, abuse or inhumanity. He fails in his duty if his investigation is superficial, slipshod or perfunctory. But the responsibility is his. He must set the bounds of the inquiry.’
Morland J ‘In my judgment the purpose of such a jury inquest under s8(3)(d) is clear. It is so that lessons can be learned from the circumstanmces of the death so that in future the risk of injuries to health and safety arising from similar circiumstances should be prevented or reduced.’
Simon Brown LJ, Morland J
Independent 27-Jan-1994, (1994) 158 JP 357
Coroners Rules 1984 36(1)
England and Wales
Cited by:
CitedMiddleton, 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.
CitedMiddleton, 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 . .
CitedIn 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 . .
CitedTakoushis, 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 . .
CitedRegina v Inner West London Coroner Ex Parte Dallaglio, and Ex Parte Lockwood Croft CA 16-Jun-1994
A coroner’s comment that the deceased’s relative was ‘unhinged’ displayed a bias which was irreparable. ‘The description ‘apparent bias’ traditionally given to this head of bias is not entirely apt, for if despite the appearance of bias the court is . .

Lists of cited by and citing cases may be incomplete.
Updated: 07 August 2021; Ref: scu.86442

In Re Northern Ireland Human Rights Commission Northern Ireland: HL 20 Jun 2002

The coroner intended to hold an inquest into the deaths on the Omagh bombing. The Commission sought the right to be involved on the basis that human rights of interest to it might arise, and the coroner refused, saying that they had no standing to do so.
Held: It was the intention in the Act to extend the powers of the commission. There were no express powers in the Act to make such an intervention, and as a purely statutory body, it had only those powers given to it. However, it had general powers to do such things as were appropriate to promote understanding of Human Rights law, and that would include the power to become involved in an inquest in the way suggested.
Lord Slynn of Hadley, Lord Woolf, Lord Nolan, Lord Hutton and Lord Hobhouse of Woodborough
Times 25-Jun-2002, [2002] UKHL 25, [2002] HRLR 35, [2002] ACD 95, [2002] NI 236
House of Lords, Bailii
Northern Ireland Act 1998 69
Northern Ireland
Citing:
CitedAttorney General and Another v Great Eastern Railway Company HL 27-May-1880
An Act of Parliament authorised a company to construct a railway. Two other companies combined and contracted with the first to supply rolling stock. An injunction was brought to try to restrain this, saying that such a contract was not explicitly . .

Cited by:
CitedHuman Rights Commission for Judicial Review (Northern Ireland : Abortion) SC 7-Jun-2018
The Commission challenged the compatibility of the NI law relating to banning nearly all abortions with Human Rights Law. It now challenged a decision that it did not have standing to bring the case.
Held: (Lady Hale, Lord Kerr and Lord Wilson . .

Lists of cited by and citing cases may be incomplete.
Updated: 25 July 2021; Ref: scu.174012

Tainton, Regina (on The Application of) v HM Senior Coroner for Preston and West Lancashire and Another: Admn 16 Jun 2016

The deceased had been a serving prisoner. He died of cancer of the oesophagus. There was concern as to his medical care. The claimant challenged the conduct of the inquest by the coroner.
Sir Brian Leveson P QBD, Kerr J
[2016] EWHC 1396 (Admin)
Bailii
England and Wales

Updated: 14 July 2021; Ref: scu.565722

Lagos, Regina (on The Application of) v HM Coroner for The City of London: Admn 14 Mar 2013

The claimant sought judicial review of decisions of the coroner at the inquest of his late wife, and in particular as to the non-disclosure by the coroner of the police report prepared for the inquest.
Held: ‘The police report is a document prepared specifically for the Coroner, which summarises the police investigation, the identity and evidence of any witnesses, and the provisional conclusions of the investigating officer. It is intended to assist the Coroner in understanding the issues and deciding which witnesses are to be called. Police reports are not adduced in evidence at inquests because they are not primary evidence.’
Lang DBE J
[2013] EWHC 423 (Admin)
Bailii
Coroners Act 1988 11, Coroners Rules 1984
England and Wales

Updated: 09 July 2021; Ref: scu.471739

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 his court would investigate the role played by the police and the local housing authority in relation to the death. The state’s duty to investigate a death was adjectival in the sense that it was ancillary to the main right to life recognised by Article 2. But it was nonetheless a freestanding right. The court stressed that Article 2 ranked as one of the most fundamental values of the Convention, enshrining (along with Article 3) one of the basic values of the democratic societies making up the Council of Europe. ‘The object and purpose of the convention as an instrument for the protection of individual human beings also requires that article 2 be interpreted and applied so as to make its safeguards practical and effective.’
Rose LJ, Henriques J
[2003] EWHC 1721 (Admin), [2004] UKHRR 139
Bailii
European Convention on Human Rights 2
England and Wales
Cited by:
CitedKhan, 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 . .
CitedIn 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 . .
CitedPlymouth 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 . .
Appeal fromHurst, 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 . .

These lists may be incomplete.
Updated: 09 June 2021; Ref: scu.185638

Mowlem Plc, Regina (on the Application Of) v District of Avon HM Assistant Deputy Coroner and Another: Admn 13 May 2005

The court has power to amend an inquisition by the substitution of words in an appropriate case. The power was only to be exercised with extreme caution: ‘The bottom line, so it seems to me, is that words can be thus substituted if they are words to which the decision-maker could not object as unreflective of his reasonable determination.’
Wilson J
[2005] EWHC 1359 (Admin)
Bailii
England and Wales
Cited by:
CitedMinistry 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 . .

These lists may be incomplete.
Updated: 03 June 2021; Ref: scu.228217

Regina v Birmingham Coroner’s Court Ex Parte Najada: CA 4 Dec 1995

At the inquest, the coroner had quizzed the applicant about his evidence but had not warned him, as he was required to do, about the possibility of self incrimination. The doctor then sought a review of the coroner’s verdict. The coroner now applied to have the judicial review adjourned pending the conclusion of other, criminal proceedings.
Held: It was for the person seeking to have a judicial review adjourned to justify the request. The applicant had a right to have it said that the coroner’s verdict had had A judicial review case should normally to be heard straight away, but it may be delayed to await the outcome of a criminal trial. If the applicant succeded at the criminal trial, the judicial review need not proceed in any event. The judge’s order adjourning the judicial review was upheld.
Neill, Auld, Iain Glidewell LJJ
Times 05-Dec-1995, Ind Summary 04-Dec-1995
England and Wales

Updated: 02 June 2021; Ref: scu.86140

Keyu and Others v Secretary of State for Foreign and Commonwealth Affairs and Another: CA 19 Mar 2014

In 1948, there had been an incident in what later became part of Malaysia, in a counter insurgency patrol, when 24 civilians were said to have been killed by a patrol from the Scots Guards. The claimant now appealed against the refusal of a further inquiry.
Held: The appeal failed.
Maurice Kay, Rimer, Fulford LJJ
[2014] 4 All ER 99, [2014] WLR(D) 138, [2015] 1 QB 57, [2014] 3 WLR 948
Bailii, WLRD
European Convention on Human Rights 2, Inquiries Act 2005 1, Human Rights Act 1998
England and Wales
Citing:
CitedIn 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 . .
Appeal fromKeyu and Others v Secretary of State for Foreign and Commonwealth Affairs and Another Admn 4-Sep-2012
It was said that a squad of the British army had caused the deaths of 24 civilians in 1948 in Batang Kali (now part of Malaysia.
Held: No inquiry was required. It was a matter of discretion, and there were no sustainable reasons for . .

Cited by:
Appeal fromKeyu and Others v Secretary of State for Foreign and Commonwealth Affairs and Another SC 25-Nov-2015
The Court was asked whether the respondents should be required to hold a public inquiry into a controversial series of events in 1948, when a Scots Guards patrol was alleged to shot and killed 24 unarmed civilians in a village called Batang Kali, in . .

These lists may be incomplete.
Updated: 01 June 2021; Ref: scu.522605

Allen, Regina (On the Application of) v Coroner for Inner North London: CA 25 Jun 2009

Dyson LJ
[2009] EWCA Civ 623, [2009] LS Law Medical 430
Bailii
England and Wales
Cited by:
CitedLewis, 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 . .

These lists may be incomplete.
Updated: 20 May 2021; Ref: scu.347195

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 been that of neglect.
Tucker J
Unreported, 18 June 1966
England and Wales
Cited by:
CitedRegina 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, . .
CitedIn 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 . .

These lists may be incomplete.
Updated: 20 May 2021; Ref: scu.237544

Guardians of the Society of Keelman on the River Tyne v Davison: 1864

(1864) 16 CBNS 612
England and Wales
Cited by:
ConsideredRegina v East Sussex Coroner Ex parte Healy QBD 1988
The death occurred whilst diving some eight or nine miles offshore. The applicant, the deceased’s father challenged the coroner’s decision to refuse jurisdiction for an inquest.
Held: The body was not, in the terms of the 1926 Act, ‘in or near . .

These lists may be incomplete.
Updated: 20 May 2021; Ref: scu.229167

P, Regina (On the Application of) v HM Coroner for the District Of Avon: Admn 5 Mar 2009

The deceased was found suspended by a sheet in her prison cell. The jury found accidental death, not being satisfied that she was not issuing a cry for help. The family appealed saying that the jury had not been directed that they could provide a narrative verdict to explain further their conclusions.
Held: The jury had not been misdirected but that, even if there had been a misdirection as claimed, he would not have remitted the matter for a new inquest because, taking into account a report of the Prisons and Probation Ombudsman published shortly before the inquest, the investigative obligation imposed upon the state by Article 2 had been effectively discharged.
Beatson J said: ‘I reject the submission that it was incumbent on the Coroner to direct the jury expressly that a narrative summary should be added to a short form verdict. That essentially would have created a hybrid. The jury had three options open to them. They were ‘enabled’ to express their conclusions on the core facts if they considered that the two short form verdicts did not do so.
I also conclude that it is possible to infer from this verdict that the accident verdict was sufficient to express the jury’s factual conclusions and conclusion that there was insufficient evidence that the 12 acts or omissions contributed to the death in more than a minimal or trivial way.’
Beatson J
[2009] EWHC 820 (Admin)
Bailii
European Convention on Human Rights 2
England and Wales
Cited by:
Appeal fromP, Regina (on The Application of) v HM Coroner for The District of Avon CA 18-Dec-2009
p_coroneravonCA2009
The deceased was found hanging in her prison cell. The jury returned a verdict of accidental death, not being satisfied that she was not merely making a cry for help. The family appealed a finding that the inquest had satisfied the requirement for a . .

These lists may be incomplete.
Updated: 20 May 2021; Ref: scu.341842

Maguire, Regina (on The Application of) v United Respons and Others: CA 10 Jun 2020

Whether the circumstances surrounding the death of Jacqueline Maguire (known as Jackie) required the coroner to allow the jury at her inquest to return an expanded conclusion in accordance with section 5(2) of the Coroners and Justice Act 2009
The Lord Burnett of Maldon
[2020] EWCA Civ 738
Bailii
Coroners and Justice Act 2009 5(2)
England and Wales

Updated: 16 May 2021; Ref: scu.651255

Green v Johnston: 1995

(Victoria High Court) Beach J: ‘In a multicultural society, such as we have in this country, it is my opinion that great weight should be given to the cultural and spiritual laws and practices of various cultural groups forming our society, and that great care should be taken to ensure that their laws and practices, assuming they are otherwise lawful, are not disregarded or abused.’
Beach J
(1995) 2 VR 176
Australia

Updated: 16 May 2021; Ref: scu.238300