Category: Coroners

Silih 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 reiterates that the provisions of the Convention do not bind a contracting party in relation to any act or fact which took place or any situation which ceased to exist before the date of the entry into force of the Convention with respect to that party or, as the case may be, prior to the entry into force of Protocol No 11, before the date on which the respondent party recognised the right of individual petition, when this recognition was still optional (the critical date). This is an established principle in the court’s case law based on the general rule of international law embodied in article 28 of the Vienna Convention’

[2009] ECHR 571, 71463/01
Bailii
European Convention on Human Rights 2
Human Rights
Citing:
See also – Silih v Slovenia ECHR 28-Jun-2007
. .

Cited by:
Cited – McCaughey and Another, Re Application forJudicial Review SC 18-May-2011
The claimants sought a fuller inquest into deaths at the hands of the British Army in 1990 in Northern Ireland. On opening the inquest, the coroner had declined to undertake to hold a hearing compliant with article 2, and it had not made progress. . .
Cited – McCaughey 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 . .
Cited – 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 . .
Cited – Finucane, Re Application for Judicial Review SC 27-Feb-2019
(Northern Ireland) The deceased solicitor was murdered in his home in 1989, allegedly by loyalists. They had never been identified, though collusion between security forces and a loyalist paramilitary was established. The ECHR and a judge led . .

Lists of cited by and citing cases may be incomplete.

Human Rights, Coroners

Updated: 16 January 2022; Ref: scu.439811

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:
Cited – In re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
Appeal from – Keyu 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 from – 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 . .
Cited – Finucane, Re Application for Judicial Review SC 27-Feb-2019
(Northern Ireland) The deceased solicitor was murdered in his home in 1989, allegedly by loyalists. They had never been identified, though collusion between security forces and a loyalist paramilitary was established. The ECHR and a judge led . .

Lists of cited by and citing cases may be incomplete.

Coroners, Armed Forces, Human Rights

Updated: 16 January 2022; Ref: scu.522605

Finucane, Re Application for Judicial Review: SC 27 Feb 2019

(Northern Ireland) The deceased solicitor was murdered in his home in 1989, allegedly by loyalists. They had never been identified, though collusion between security forces and a loyalist paramilitary was established. The ECHR and a judge led inquiry had said that a proper investigation was required. A promised inquiry under the 2005 Act was objected to by the claimant, but a public inquiry was rejected in 2011, and an independent review ordered. That review had its own difficulties.
Held: The claimant had a legitimate expectation of a public inquiry, but the decision against was not made in bad faith and was made on genuine policy grounds. There had been an article 2 compliant investigation.

Lady Hale (President), Lord Kerr, Lord Carnwath, Lord Hodge, Lady Black
[2019] UKSC 7, [2019] NI 292, [2019] Inquest LR 71, [2019] HRLR 7, [2019] 3 All ER 191
Bailii, Bailii Summary, SC, SC Summary, SC Video Summary, SC 18 Jun 26 am Video, SC 18 Jun pm Video, SC 18 Jun 27 am Video, SC 18 Jun 27 pm Video
Inquiries Act 2005
Northern Ireland
Citing:
Cited – Associated Provincial Picture Houses Ltd v Wednesbury Corporation CA 10-Nov-1947
Administrative Discretion to be Used Reasonably
The applicant challenged the manner of decision making as to the conditions which had been attached to its licence to open the cinema on Sundays. It had not been allowed to admit children under 15 years of age. The statute provided no appeal . .
Cited – Regina v Inland Revenue Commission ex parte Preston; In re Preston HL 1984
Duty of Fairness to taxpayer – Written Assurance
The applicant was assured by the Inland Revenue that it would not raise further inquiries on certain tax affairs if he agreed to forgo interest relief which he had claimed and to pay a certain sum in capital gains tax.
Held: Where the . .
Appeal from – Finucane v The Secretary of State for Northern Ireland CANI 21-Feb-2017
The appellant seeks to vary the order made by Stephens J whereby he refused to order the Secretary of State for Northern Ireland to hold a public inquiry into the murder of the husband of the appellant Patrick Finucane (”PF”) and the respondent . .
Cited – Mandalia v Secretary of State for The Home Department SC 14-Oct-2015
The Court considered the guidance given to UK Border Agency case workers when considering document submitted by persons applying for leave to enter or stay in the UK as foreign students. M had applied to study here, but had not accompanied his . .
Cited – In 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 . .
Cited – Janowiec 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 . .
Cited – Mocanu and Others v Romania ECHR 17-Sep-2014
. .
Cited – Regina v Inland Revenue Commissioners, ex parte MFK Underwriting Agents Ltd CA 1990
Legitimate Expectation once created not withdrawn
The claimant said that a change of practice by the Revenue was contrary to a legitimate expectation.
Held: The Inland Revenue could not withdraw from a representation if it would cause: substantial unfairness to the applicant; if the . .
Cited – 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 . .
Cited – McCann and Others v The United Kingdom ECHR 6-Oct-1995
Wrong assumptions made by police officers in the killing of terrorists amounted to a human rights breach, despite the existence of danger to the public of an imminent attack. Article 2(1) is ‘one of the most fundamental provisions in the . .
Cited – Regina v Secretary of State for Home Department and Governor of Her Majesty’s Prison Risley ex parte Hargreaves, Briggs and Green CA 20-Nov-1996
No sufficient expectation which could form the basis of a judicial review arose from an agreement for prison home leave which was later denied. The only legitimate expectation of the prisoners was to have their applications individually considered . .
Cited – Mladenovic v Serbia ECHR 22-May-2012
. .
Cited – McCaughey and Another, Re Application forJudicial Review SC 18-May-2011
The claimants sought a fuller inquest into deaths at the hands of the British Army in 1990 in Northern Ireland. On opening the inquest, the coroner had declined to undertake to hold a hearing compliant with article 2, and it had not made progress. . .
Cited – Regina v North and East Devon Health Authority ex parte Coughlan and Secretary of State for Health Intervenor and Royal College of Nursing Intervenor CA 16-Jul-1999
Consultation to be Early and Real Listening
The claimant was severely disabled as a result of a road traffic accident. She and others were placed in an NHS home for long term disabled people and assured that this would be their home for life. Then the health authority decided that they were . .
Cited – Paponette and Others v Attorney General of Trinidad and Tobago PC 13-Dec-2010
The appellants operated taxis in Port-of-Spain. The Minister proposed changes, but when challenged provided re-assurances. After the changes, the re-assurances were not satisfied. The claimants sought judicial review asserting that a legitimate . .
Cited – Silih 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 . .
Cited – Bancoult, Regina (on the Application of) v Secretary of State for Foreign and Commonwealth Affairs (No 2) HL 22-Oct-2008
The claimants challenged the 2004 Order which prevented their return to their homes on the Chagos Islands. The islanders had been taken off the island to leave it for use as a US airbase. In 2004, the island was no longer needed, and payment had . .
Cited – Regina v Department of Education and Employment ex parte Begbie CA 20-Aug-1999
A statement made by a politician as to his intentions on a particular matter if elected could not create a legitimate expectation as regards the delivery of the promise after elected, even where the promise would directly affect individuals, and the . .
Cited – Regina (Holding and Barnes plc) v Secretary of State for Environment Transport and the Regions; Regina (Alconbury Developments Ltd and Others) v Same and Others HL 9-May-2001
Power to call in is administrative in nature
The powers of the Secretary of State to call in a planning application for his decision, and certain other planning powers, were essentially an administrative power, and not a judicial one, and therefore it was not a breach of the applicants’ rights . .
Cited – Bhatt Murphy (a firm), Regina (on the application of) v The Independent Assessor CA 9-Jul-2008
The appellants each challenged alterations to the scheme for compensation of the victims of miscarriages of justice.
Held: Laws LJ emphasised the special nature of the promise or practice which was necessary to give rise to a substantive . .
Cited – Brecknell 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 . .
Cited – Calvelli and Ciglio v Italy ECHR 17-Jan-2002
The applicants’ baby had died shortly after birth in 1987. They complained about the medical care. The complaint was not investigated speedily by the authority, resulting in a criminal complaint becoming time barred after a conviction in 1994 was . .
Cited – Byrzykowski v Poland ECHR 27-Jun-2006
. .
Cited – Blecic 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 . .
Cited – AN, Regina (on the Application of) v Mental Health Review Tribunal (Northern Region) and others CA 21-Dec-2005
The appellant was detained under section 37 of the 1983 Act as a mental patient with a restriction under section 41. He sought his release.
Held: The standard of proof in such applications remained the balance of probabilities, but that . .
Cited – Regina (Reprotech (Pebsham) Ltd) v East Sussex County Council Reprotech (Pebsham) Ltd v Same HL 28-Feb-2002
The respondent company had asserted that the local authority had made a determination of the issue of whether electricity could be generated on a waste treatment site without further planning permission. The council said that without a formal . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Regina (Nadarajah) v Secretary of State for the Home Department; Abdi v Secretary of State for the Home Department CA 22-Nov-2005
The asylum applicant challenged a certificate given by the respondent that the claim for asylum was manifestly ill-founded. The respondent had made a mistake in applying the appropriate policy, but had sought to correct the error. The claimants . .
Cited – Ramsahai 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 . .
Cited – In re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
Cited – Nachova 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 . .
Cited – Regina 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 . .

Lists of cited by and citing cases may be incomplete.

Coroners, Human Rights

Updated: 16 January 2022; Ref: scu.634240

Bennett, Regina (on The Application of) v HM Coroner for Inner South London: Admn 3 Feb 2006

The deceased had been shot by a police officer. The family now challenged the refusal of the coroner to leave to the jury at the inquest a verdict of unlawful killing.
Held: The claim failed.

Collins J
[2006] EWHC 196 (Admin), [2006] HRLR 22, [2006] Inquest LR 21, [2006] Po LR 123, (2006) 170 JP 109
Bailii
England and Wales

Coroners, Human Rights, Police

Updated: 12 January 2022; Ref: scu.561481

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

A prisoner had hanged himself after being left unsupervised in a single cell. He was a known suicide risk, but the Coroner directed the jury not to return a verdict which included any reference to lack of care.
Held: A coroner was free not to 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
England and Wales
Cited by:
Appeal from – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – O’Reilly v Coventry Coroner QBD 3-Apr-1996
The inquest was said to have been flawed because relevant material was withheld from the jury, factual issues were not addressed, and the Coroner had refused to leave open the possibility of a verdict of lack of care or neglect. The deceased had . .
Cited – Takoushis, Regina (on the Application of) v HM Coroner for Inner North London and others CA 30-Nov-2005
Relatives sought judicial review of the coroner’s decision not to allow a jury, and against allowance of an expert witness. The deceased had been a mental patient but had been arrested with a view to being hospitalised. He was taken first to the . .
Cited – In re Catherine Lucy Clegg (an Application to Quash Inquisition on Inquest) Admn 2-Dec-1996
The father of the deceased sought an order quashing the inquest on her death. He had recorded a verdict of suicide. She had died from acute salicylate poisoning, an aspirin overdose. The hospital was said not to have recognised her condition and not . .
Cited – Parkin v HM Coroner for North Lincolnshire and Grimsby District Admn 23-Mar-2005
The family appealed against an open verdict. Her son was found hanged at school. The coroner felt unable to be sure that he had committed suicide. He had been looking forward to a new job as a theatre technician.
Held: There was evidence . .
Cited – Assistant Deputy Coroner of Inner West London v Paul and Another, Regina on the Application of CA 28-Nov-2007
The coroner appealed a judicial review granted after he allowed into evidence, hearsay evidence contained in a written statemnent from a witness who could not attend the inquest.
Held: Rule 37 does not allow the admission of a document, even . .
Cited – Regina 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, . .
Cited – Hurst, Regina (on the Application of) v Commissioner of Police of the Metropolis v London Northern District Coroner HL 28-Mar-2007
The claimant’s son had been stabbed to death. She challenged the refusal of the coroner to continue with the inquest with a view to examining the responsibility of any of the police in having failed to protect him.
Held: The question amounted . .

Lists of cited by and citing cases may be incomplete.

Coroners, Prisons

Leading Case

Updated: 12 January 2022; Ref: scu.87445

Wood v An Inquest: SCS 21 Nov 1561

Anent the summons raised at the Queen’s Grace’s instance, and John Wood, for his interest, against A., and others of Inquest, for manifest and will error for serving of Walter Wood, second son of umquhile G. Wood, as heir to the said G., of certain lands, howbeit of verity the said John, eldest son to the said G., was in life the time of the said serving, and yet is nearest and lawful heir to his said father. It was alleged for the said Inquest, That the said John Wood, eldest son foresaid, was, in time of the serving, and seven years immediately continually before, forth of the country, and reputed a dead man, by his father and the whole country.; wherefore, the said Inquest should be assoilzied of wilful error; which allegeance was found relevant, and admitted by the Lords, and the said Inquest assoilzied from wilful error.

[1561] Mor 14081
Bailii
Scotland

Coroners

Updated: 10 January 2022; Ref: scu.560410

Flower v HM Coroner for The County of Devon, Plymouth, Torbay and South Devon and Another: Admn 16 Dec 2015

The claimant sought an order quashing the inquest into the death of her son, but the inquest had not yet been formally concluded. It had been opened but suspended pending the completion of criminal proceedings, and a later decision had been made to to resume the investigation.
Held: The application must fail. It remained open to the claimant to invite the coroner to resume his inquest.

McCombe J, Thornton QC Chief Coroner
[2015] EWHC 3666 (Admin)
Bailii
Coroners Act 1988
England and Wales

Coroners

Updated: 08 January 2022; Ref: scu.557144

Kennedy and Another v The Lord Advocate: SCS 5 Feb 2008

These petitions were raised by the relatives of two people, who died after they had become infected with the Hepatitis C virus. That infection occurred whilst they were under the care of the National Health Service in Scotland. The Lord Advocate refused to hold Fatal Accident Inquiries into the deaths of the deceased. The petitioners seek the judicial review of those decisions. The petitioners also seek review of the refusal of the Scottish Ministers to set up public inquiries into those deaths.

Lord Mackay of Drumadoon
[2008] ScotCS CSOH – 21
Bailii
Scotland

Coroners, Health

Updated: 06 January 2022; Ref: scu.264109

LF, Regina (on The Application of) v HM Senior Coroner for Inner South London and Another: Admn 29 Oct 2015

The claimant whose daughter, suffering Down’s Syndrome, had died while in intensive care in hospital, challenged the rejection of her argument that her daughter had been in ‘state detention’ at the time.

Gross LJ, Charles J
[2015] EWHC 2990 (Admin), (2016) 180 JP 85, [2016] 1 WLR 2385, [2015] WLR(D) 442, [2016] COPLR 119, [2015] Inquest LR 293, 180 JP 85
Bailii, WLRD
Coroners and Justice Act 2009
England and Wales

Coroners

Updated: 05 January 2022; Ref: scu.554195

Zarkovic And Others v Croatia (Dec): ECHR 9 Jun 2015

ECHR Article 37-1
Striking out applications
Acknowledgment of violation in a unilateral declaration: struck out
Facts – The applicants’ relative disappeared following military action by the Croatian authorities in 1995. No investigation was opened into the circumstances of his disappearance or death. The applicants brought a civil claim against the State seeking damages but this was dismissed by a municipal court which found that their relative’s death had to be considered war damage in the absence of proof that he had been killed by Croatian soldiers or police. The judgment was upheld by a county court which stated that the presence of Croatian army and police itself could not be accepted as proof that the applicants’ relative had been killed by them. The Supreme Court dismissed the applicants’ appeal and their subsequent constitutional complaint was declared inadmissible.
Law – Article 37: The applicants had alleged that the Croatian authorities had failed, in breach of Articles 2 and 14 of the Convention, to take appropriate and adequate steps to investigate the circumstances of their relative’s death. By a letter of 17 December 2014 the Croatian Government made a unilateral declaration acknowledging a violation of those provisions and offered to pay the applicants EUR 18,900 jointly to cover any non-pecuniary damage and costs and expenses. The applicants rejected the offer considering the sum too low and insisted on the examination of their other complaints.
The Court reiterated that it could strike out an application under Article 37 – 1 (c) on the basis of a unilateral declaration by a respondent Government even if the applicant wished the examination of the case to be continued. It noted that the Government had explicitly acknowledged violations of Articles 2 and 14 of the Convention and that the proposed sum was not unreasonable in comparison with the awards made by the Court in similar cases. The complaints raised were based on the Court’s clear and extensive case-law finding violations of Articles 2 and 14 of the Convention for inadequate investigations into the killings or ill-treatment of applicants or their relatives. As the Committee of Ministers remained competent to supervise the implementation of judgments, the Court was satisfied that it was not required to continue its examination of the inadequacies in the investigation into the killing of the applicants’ relative. Instead, it decided to strike this part of the application out of the list without prejudice to the Government’s continuing obligation to conduct an investigation in compliance with the requirements of the Convention.
Conclusion: struck out (unanimously).

Article 6 – 1: The applicants had been afforded the possibility of bringing judicial proceedings for compensation. The domestic courts had examined the applicants’ claim on the merits and found that they had failed to prove that the victim had actually been killed by Croatian soldiers. That conclusion of the national court was not arbitrary or manifestly unreasonable.

Conclusion: inadmissible (manifestly ill-founded).

75187/12 – Legal Summary, [2015] ECHR 754
Bailii
European Convention on Human Rights
Human Rights

Human Rights, Constitutional, Coroners

Updated: 03 January 2022; Ref: scu.552053

Shafi v HM Senior Coroner for East London: Admn 20 Jul 2015

The claimant’s son had died in a prison attached to a police station in Dubai. She sought a new inquest saying that the first had been inadequate.
Held: A new inquest was ordered. There had been difficulties in that the Dubai authorities had failed to supply CCTV evidence. More decisively however, the coroner had failed to raise the possibility of Dubai witnesses giving evidence

Bean LJ, Peter Thornton QC HHJ, Chief Coroner
[2015] EWHC 2106 (Admin)
Bailii
Coroners and Justice Act 2009 1(2)(b), Coroners (Inquests) Rules 2013
Citing:
Cited – 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 . .
Cited – In Re Neal (Coroner: Jury) QBD 17-Nov-1995
The father of the deceased sought to have the coroner quash the inquest. His daughter had died in Spain from carbon monoxide poisoning, apparently emanated from a faulty water heater in the apartment in which she had stayed. Her body had been . .
Cited – Paul and others v Deputy Coroner of the Queen’s Household and Another Admn 2-Mar-2007
The applicants sought judicial review of preliminary directions given for the intended inquest on the deaths of Diana Princess of Wales and of Dodi Al Fayed. It was submitted that the jurisdiction had been wrongly transferred to the Queen’s Coroner . .

Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 02 January 2022; Ref: scu.550384

Long, Regina (on The Application of) v Secretary of State for Defence: CA 17 Jul 2015

The claimant appealed against a refusal of a declaration that (i) a declaration that the defendant, the Secretary of State for Defence, had acted in breach of article 2 and (ii) an order requiring him to conduct an effective independent investigation into the death of her son, one of six British soldiers of the Royal Military Police who had been murdered by an armed mob when visiting a police station in Majar-al-Kabir, Maysan Province, Iraq on 24 June 2004 in the course of their mission to help restore and maintain law and order by rebuilding the local police force.
Held: The appeal failed. The death of a soldier on active service abroad was necessary under article 2 when the circumstances suggested a systematic permitting of soldiers routinely to disregard a communications order. It was enough to show a failure to take reasonable measures which may have of avoiding the death.
Where the investigative process of an Army Board of Inquiry and a coroner’s inquest had revealed sufficiently why a system failure had occurred, what had gone wrong and what lessons were to be learnt, the obligation under article 2 was discharged.

Lord Dyson MR, Lewison, Underhill LJJ
[2015] EWCA Civ 770, [2015] WLR(D) 320
Bailii, WLRD
European Convention on Human Rights 2
England and Wales

Armed Forces, Human Rights, Coroners

Updated: 02 January 2022; Ref: scu.550370

Finucane, Re Judicial Review: QBNI 26 Jun 2015

Application by Geraldine Finucane for judicial review of 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.’ The applicant challenged both (a) the decision of the SOSNI not to hold a public inquiry of that kind into his death and also (b) the decision to establish an independent review of the circumstances of his death.

[2015] NIQB 57
Bailii
Northern Ireland

Coroners, Administrative

Updated: 01 January 2022; Ref: scu.549492

Ciobanu v The Republic of Moldova: ECHR 24 Feb 2015

The applicant alleged, in particular, that the domestic authorities had failed to conduct an appropriate investigation into her husband’s death, contrary to their obligations under Article 2 of the Convention.

Josep Casadevall, P
62578/09 – Chamber Judgment, [2015] ECHR 218
Bailii
European Convention on Human Rights 2

Human Rights, Coroners

Updated: 28 December 2021; Ref: scu.543240

Mileusnic And Mileusnic-Espenheim v Croatia: ECHR 19 Feb 2015

The applicants alleged, in particular, that, contrary to the procedural requirement under Article 2 of the Convention, there has been no adequate response by the national authorities to the killing of their close relatives.

Isabelle Berro, P
66953/09 – Chamber Judgment, [2015] ECHR 197
Bailii
European Convention on Human Rights

Human Rights, Coroners

Updated: 28 December 2021; Ref: scu.543076

Skelton, Regina (on The Application of) v Senior Coroner for West Sussex: Admn 23 Oct 2020

The claimants daughter’s death had first been declared non-suspicious. After a conviction for her murder, the Coroner sought to substitute a verdict of unlawful killing. The claimant objected saying that a wider enquiry was no justified, particularly as to the failures of the police investigation.

Lord Justice Popplewell,
Mr Justice Jay
[2020] EWHC 2813 (Admin), [2020] WLR(D) 578, (2021) 177 BMLR 167, [2021] 2 WLR 413, [2021] QB 525
Bailii, WLRD
Coroners Act 1988 13
England and Wales

Coroners

Updated: 28 December 2021; Ref: scu.655215

Regina (on the Application of Jean Marshall) v Her Majesty’s Coroner for Coventry: Admn 22 Oct 2001

The applicant sought judicial review of the verdict of the coroner’s jury that a death had been accidental. The deceased, a schizophrenic died of an overdose of crack cocaine, whilst in police custody. His family sought a verdict of accidental death contributed to by neglect.
Held: In this case the possibility of such a finding would arise if the custody officer had known of the ingestion of cocaine but had failed to act, Here, the deceased had lied about what he had done, but the officer had called the police surgeon. The review was denied.

The Honourable Mr Justice Hooper
[2001] EWHC Admin 804
Bailii
England and Wales
Cited by:
Cited – Khan, Regina (on the Application of) v HM Coroner for West Hertfordshire and Another Admn 7-Mar-2002
The deceased died in police custody. The coroner refused to leave to the jury possible verdicts of unlawful killing, or death contributed to by neglect, or breach of his right to life. He adjourned the hearing to allow this challenge.
Held: . .

Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 16 December 2021; Ref: scu.167248

Mcquillan, Mcguigan and Mckenna, Re Application for Judicial Review: SC 15 Dec 2021

The appellants had relatives who died at the hands of the authorities in the 1970’s in Northern Ireland. They said that the obligation to investigate their deaths was continuing and remained unsatisfied.

Lord Hodge, Deputy President,
Lord Lloyd-Jones,
Lord Kitchin,
Lord Sales,
Lord Hamblen,
Lord Leggatt,
Lord Burrows
[2021] UKSC 55
Bailii, Bailii Summary, Bailii Issues and Facts
European Convention on Human Rights
Northern Ireland

Human Rights, Coroners

Updated: 16 December 2021; Ref: scu.670455

Regina 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 able to examine all the relevant material and satisfy itself that there was no danger [possibility] of the alleged bias having in fact caused injustice, the impugned decision will be allowed to stand’ and ‘the court’s task is to ascertain the relevant circumstances and ask itself whether, having regard to these circumstances, there was a real danger of bias on the part of HM Coroner for Inner West London in the sense that he might have unfairly regarded with disfavour the cases of the applicants as parties to an issue under consideration by him.’
Simon Brown LJ analysed the case of R v Gough: ‘From R v. Gough I derive the following propositions: (1) Any court seised of a challenge on the ground of apparent bias must ascertain the relevant circumstances and consider all the evidence for itself so as to reach its own conclusion on the facts. (2) It necessarily follows that the factual position may appear quite differently as between the time when the challenge is launched and the time when it comes to be decided by the court. What may appear at the leave stage to be a strong case of justice `not manifestly and undoubtedly being seen to be done’, may, following the court’s investigation, nevertheless fail. Or, of course, although perhaps less probably, the case may have become stronger. (3) In reaching its conclusion the court `personifies the reasonable man’. (4) The question upon which the court must reach its own factual conclusion is this: is there a real danger of injustice having occurred as a result of bias? By ‘real’ is meant not without substance. A real danger clearly involves more than a minimal risk, less than a probability. One could, I think, as well speak of a real risk or a real possibility. (5) Injustice will have occurred as a result of bias `if the decision-maker unfairly regarded with disfavour the case of a party to the issue under consideration by him’. I take `unfairly regarded with disfavour’ to mean `was pre-disposed or prejudiced against one party’s case for reasons unconnected with the merits of the issue’. (6) A decision-maker may have unfairly regarded with disfavour one party’s case either consciously or unconsciously. Where, as here, the applicants expressly disavow any suggestion of actual bias, it seems to me that the court must necessarily be asking itself whether there is a real danger that the decision-maker was unconsciously biased. (7) It will be seen, therefore, that by the time the legal challenge comes to be resolved, the court is no longer concerned strictly with the appearance of bias but rather with establishing the possibility that there was actual although unconscious bias.’

Simon Brown LJ, Sir Thomas Bingham MR
Independent 17-Jun-1994, Times 16-Jun-1994, [1994] 4 All ER 139
England and Wales
Citing:
Explained – Regina v Gough (Robert) HL 1993
The defendant had been convicted of robbery. He appealed, saying that a member of the jury was a neighbour to his brother, and there was therefore a risk of bias. This was of particular significance as the defendant was charged with conspiracy with . .
Explained – Rex v Sussex Justices, Ex parte McCarthy KBD 9-Nov-1923
Clerk wrongly retired with Justices
There had been a prosecution before the lay magistrates for dangerous driving. Unknown to the defendant and his solicitors, the Clerk to the Justices was a member of the firm of solicitors acting in a civil claim against the defendant arising out of . .
Cited – Regina v Coroner for Western District of Sussex Ex Parte Homberg Roberts and Mannerss QBD 27-Jan-1994
A Coroner’s enquires should be as to ‘how’ the death arose, and not into all the circumstances contributing to the death.
Simon Brown LJ said: ‘It is clear that the coroner’s over-riding duty is to inquire ‘how’ the deceased came by his death . .

Cited by:
Cited – Cairnstores Ltd Generics (UK) Ltd and Another v Aktiebolaget Hassle CA 22-Oct-2002
Two patents had been invaildated for obviousness. They related to coatings on medicinal pills. The patent holder said the judge’s interruptions indicated bias.
Held: The sumissions were unjustified. The interventions were by no means . .
Cited – Regina v Stipendiary Magistrate for Norfolk ex parte Dean Taylor Admn 1-Jul-1997
The prosecutor applied ex parte to the magistrate for an order that he need not disclose certain material to the defendant. Though the hearing was inter partes, the content of the protected material was not shown to the defendant’s solciitor. . .
Cited – Regina v H; Regina v C HL 5-Feb-2004
Use of Special Counsel as Last Resort Only
The accused faced charges of conspiring to supply Class A drugs. The prosecution had sought public interest immunity certificates. Special counsel had been appointed by the court to represent the defendants’ interests at the applications.
Cited – Lodwick v London Borough of Southwark CA 18-Mar-2004
The claimant alleged bias on the part of the employment appeal tribunal chairman hearing his appeal. The chairman refused to stand down, saying that he was only one of three tribunal members with an equal vote. The chairman had four year’s . .
Cited – In Re Medicaments and Related Classes of Goods (No 2); Director General of Fair Trading v Proprietary Association of Great Britain and Proprietary Articles Trade Association CA 21-Dec-2000
The claimants alleged that a connection between a member of the Restrictive Practices Court, who was to hear a complaint and another company, disclosed bias against them. She had not recused herself.
Held: When asking whether material . .
Cited – Flaherty v National Greyhound Racing Club Ltd CA 14-Sep-2005
The club regulated greyhound racing. The claimant had complained that its disciplinary proceedings had been conducted unfairly. He said that a panel member had an interest as veterinary surgeon in the proceedings at the stadium at which the alleged . .
Cited – Takoushis, Regina (on the Application of) v HM Coroner for Inner North London and others CA 30-Nov-2005
Relatives sought judicial review of the coroner’s decision not to allow a jury, and against allowance of an expert witness. The deceased had been a mental patient but had been arrested with a view to being hospitalised. He was taken first to the . .
Cited – Hurst, Regina (on the Application of) v Commissioner of Police of the Metropolis v London Northern District Coroner HL 28-Mar-2007
The claimant’s son had been stabbed to death. She challenged the refusal of the coroner to continue with the inquest with a view to examining the responsibility of any of the police in having failed to protect him.
Held: The question amounted . .
Cited – McKeown v British Horseracing Authority QBD 12-Mar-2010
The jockey claimant challenged disciplinary proceedings brought against him by the defendant authority.
Held: The findings were upheld in part but remitted for consideration of giving the claimant opportunity to challenge certain evidence. . .
Cited – 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 . .
Cited – Locabail (UK) Ltd, Regina v Bayfield Properties Ltd CA 17-Nov-1999
Adverse Comments by Judge Need not be Show of Bias
In five cases, leave to appeal was sought on the basis that a party had been refused disqualification of judges on grounds of bias. The court considered the circumstances under which a fear of bias in a court may prove to be well founded: ‘The mere . .

Lists of cited by and citing cases may be incomplete.

Coroners, Natural Justice

Updated: 11 December 2021; Ref: scu.86950

Adath Yisroel Burial Society and Another, Regina (on The Application of) v HM Senior Coroner for Inner North London: Admn 27 Apr 2018

The Society challenged the refusal of the coroner to expedite of deaths for religious reasons, alleging discrimination against Jewish and Muslim families in breach of Convention or statutory rights.
Held: Allowed in part.

Singh LJ, Whipple J
[2018] EWHC 969 (Admin), [2019] QB 251, [2018] WLR(D) 273, (2018) 162 BMLR 217, [2018] HRLR 15, [2018] 3 WLR 1354, [2018] Med LR 410, [2018] Inquest LR 100, [2018] 3 All ER 1088
Bailii, WLRD
Human Rights Act 1998, European Convention on Human Rights, Equality Act 2010
England and Wales

Coroners, Human Rights, Discrimination

Updated: 06 December 2021; Ref: scu.614955

LM, 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 the orders.
Held: The orders should be lifted to the extent compatible with preserving the child’s interests. Sir Mark Potter P recognised that the principle of open justice ‘extends to the right of the media freely to report the identity of the defendant and witnesses in criminal proceedings despite the adverse effects on the Art 8 rights of a child who was not so involved.’

Sir Mark Potter P
[2007] EWHC 1902 (Fam)
Bailii
Coroners Act 1988
England and Wales
Citing:
See Also – A Local Authority v K, D and L FD 8-Mar-2005
The court gave guidance on the approach to expert evidence in children’s cases. Charles J said ”in determining the facts, a court should have regard to the guidance given in R v Lucas (Ruth) [1981] QB 720 and R v Middleton [2000] TLR 203. As . .
Cited – Scott v Scott HL 5-May-1913
Presumption in Favour of Open Proceedings
There had been an unauthorised dissemination by the petitioner to third parties of the official shorthand writer’s notes of a nullity suit which had been heard in camera. An application was made for a committal for contempt.
Held: The House . .
Cited – Attorney-General v Leveller Magazine Ltd HL 1-Feb-1979
The appellants were magazines and journalists who published, after committal proceedings, the name of a witness, a member of the security services, who had been referred to as Colonel B during the hearing. An order had been made for his name not to . .
Cited – A Local Authority v PD and others FD 10-Aug-2005
Application by a number of newspapers in order to clarify the terms and effect of an injunction granted in the course of care proceedings under The Children Act 1989 relating to a six-year old child . .
Cited – A Local Authority v W L W T and R; In re W (Children) (Identification: Restrictions on Publication) FD 14-Jul-2005
An application was made by a local authority to restrict publication of the name of a defendant in criminal proceedings in order to protect children in their care. The mother was accused of having assaulted the second respondent by knowingly . .
Cited – In re S (a Child) (Identification: Restrictions on Publication) HL 28-Oct-2004
Inherent High Court power may restrain Publicity
The claimant child’s mother was to be tried for the murder of his brother by poisoning with salt. It was feared that the publicity which would normally attend a trial, would be damaging to S, and an application was made for reporting restrictions to . .
Cited – Regina v Legal Aid Board ex parte Kaim Todner (a Firm of Solicitors) CA 10-Jun-1998
Limitation on Making of Anonymity Orders
A firm of solicitors sought an order for anonymity in their proceedings against the LAB, saying that being named would damage their interests irrespective of the outcome.
Held: The legal professions have no special part in the law as a party . .
Cited – Allan v Clibbery (1) CA 30-Jan-2002
Save in cases involving children and ancillary and other situations requiring it, cases in the family division were not inherently private. The appellant failed to obtain an order that details of an action under the section should not be disclosed . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – Regina v Bedfordshire Coroner ex parte Local Sunday Newspapers Ltd 1999
The test of whether a coroner should grant anonimity to a witness involved a decision on whether or not there was objective evidence to show that the fears of the Respondent established a serious or real possibility of danger to life. Burton J . .

Cited by:
Cited – H v A (No2) FD 17-Sep-2015
The court had previously published and then withdrawn its judgment after third parties had been able to identify those involved by pulling together media and internet reports with the judgment.
Held: The judgment case should be published in . .

Lists of cited by and citing cases may be incomplete.

Coroners, Media

Updated: 06 December 2021; Ref: scu.258496

RJ, Regina (on The Application of) v The Director of Legal Aid Casework: Admn 22 Mar 2016

The claimant challenged a decision of the Director of Legal Aid Casework to refuse her application for legal aid to enable her to be represented at an inquest.

Leggatt J
[2016] EWHC 645 (Admin)
Bailii
England and Wales
Citing:
Cited – Saunders v The United Kingdom ECHR 17-Dec-1996
(Grand Chamber) The subsequent use against a defendant in a prosecution, of evidence which had been obtained under compulsion in company insolvency procedures was a convention breach of Art 6. Although not specifically mentioned in Article 6 of the . .

Lists of cited by and citing cases may be incomplete.

Coroners, Legal Aid

Updated: 04 December 2021; Ref: scu.561488

JL, Regina (on the Application of) v Secretary of State for the Home Department: Admn 1 Nov 2006

Duty to investigate attempted suicide in prison.

Langstaff J
[2006] EWHC 2558 (Admin), [2006] Inquest LR 200, [2007] ACD 31
Bailii
England and Wales
Cited by:
Appeal from – JL, Regina (on the Application of) v Secretary of State for the Home Department CA 24-Jul-2007
The court was asked to order a public enquiry into an attempted suicide in prison. Waller LJ was anxious about the task of defining suicide and near suicide: ‘I am clear that the simple fact of a death or serious injury of a person in custody gives . .

Lists of cited by and citing cases may be incomplete.

Prisons, Human Rights, Coroners

Updated: 03 December 2021; Ref: scu.245782

Lewin v Crown Prosecution Service: Admn 24 May 2002

The applicant sought review of the decision of the respondent not to initiate a prosecution in respect of a death in Spain. The deceased had been left drunk and unconscious in a car in the sun. There was a variance of opinion as to the exact cause of death, but it was said the proposed defendant should not have left him in a car in the hot sun.
Held: A decision not to prosecute is susceptible to judicial review, but that should be sparingly exercised. The duty of care assumed by bringing the deceased home in the car could not be extended to care for him afterwards. Application for review dismissed.

Mrs Justice Hallett
[2002] EWHC 1049 (Admin)
Bailii
England and Wales
Citing:
Cited – C (A Minor) v Director of Public Prosecutions HL 17-Mar-1995
The House considered whether the long established rule of the criminal law presuming that a child did not have a guilty mind should be set aside.
Held: Doli incapax, the presumption of a child’s lack of mens rea, is still effective and good . .

Lists of cited by and citing cases may be incomplete.

Coroners, Crime, Judicial Review

Updated: 03 December 2021; Ref: scu.171268

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:
Cited – Regina v HM Coroner, Lincoln, ex parte Hay 19-Feb-1987
. .
Cited – In re Rapier (Deceased) QBD 1988
A young prisoner had been found dead in his cell hanging. A report suggested that he may have been sniffing solvents. The coroner himself initiated proceedings both under the Coroners’ Act and for judicial review to quash the inquisition over which . .

Cited by:
See Also – 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 . .

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:
Cited – Secretary 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:
Cited – Finn-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

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 from – 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 . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Regina (Cash) v County of Northamptonshire Coroner Admn 2007
. .
Cited – Amin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
Prisoner’s death – need for full public enquiry
The deceased had been a young Asian prisoner. He was placed in a cell overnight with a prisoner known to be racist, extremely violent and mentally unstable. He was killed. The family sought an inquiry into the death.
Held: There had been a . .

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 from – Regina v HM Coroner for Inner London (ex parte Lisa Douglas-Williams) Admn 31-Jul-1997
. .
Cited – Regina v Galbraith CCA 1981
Rejection of Submission of No Case to Answer
The defendant had faced a charge of affray. The court having rejected his submission of having no case to answer, he had made an exculpatory statement from the dock. He appealed against his conviction.
Held: Lord Lane LCJ said: ‘How then . .

Cited by:
Cited – Regina on the Application of Mullholland v HM Coroner for St Pancras QBD 7-Nov-2003
The applicant sought to re-open a coroner’s inquest. The deceased had been drunk, slipped banged his head and fallen to the ground. Police and ambulance were called. The ambulance worker was not told he had been unconscious, and he was taken to the . .
Cited – Regina (Anderson and Others) v HM Coroner for Inner North Greater London QBD 26-Nov-2004
The deceased suffered depressive mental illness, and was detained outside on a cold night naked and in a cannabis induced delirium. Because of his size, additional officers were called upon to assist restraining him. He was taken to hospital, but . .
Cited – Regina (Anderson and Others) v HM Coroner for Inner North Greater London QBD 26-Nov-2004
The deceased suffered depressive mental illness, and was detained outside on a cold night naked and in a cannabis induced delirium. Because of his size, additional officers were called upon to assist restraining him. He was taken to hospital, but . .
See Also – Regina v Inner London South District Coroner Ex Parte Douglas-Williams CA 30-Jul-1998
A coroner had the right not to leave all possible verdicts to a jury, even including one possibly supported by the evidence, where the overwhelming evidence pointed one way, and possible confusion of jury might be caused by leaving all verdicts to . .

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:
Cited – Amin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
Prisoner’s death – need for full public enquiry
The deceased had been a young Asian prisoner. He was placed in a cell overnight with a prisoner known to be racist, extremely violent and mentally unstable. He was killed. The family sought an inquiry into the death.
Held: There had been a . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Holgate-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 . .
Cited – C, 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 . .
Cited – Al-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:
Cited – Smith, Regina (on The Application of) v Secretary of State for Defence and Oxfordshire Assistant Deputy Coroner (Equality and Human Rights Commission intervening) SC 30-Jun-2010
The deceased soldier died of heat exhaustion whilst on active service in Iraq. It was said that he was owed a duty under human rights laws, and that any coroner’s inquest should be a fuller one to satisfy the state’s duty under Article 2.
Cited – Khan, Regina (on the Application of) v Secretary of State for Health CA 10-Oct-2003
The claimant’s child had died as a result of negligence in hospital. The parents had been told the result of police investigation and decision not to prosecute, and the hospital’s own investigation, but had not been sufficiently involved. There . .
Cited – Stephen 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 . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Gentle, Regina (on the Application of) and Another v The Prime Minister and Another HL 9-Apr-2008
The appellants were mothers of two servicemen who had died whilst on active service in Iraq. They appealed refusal to grant a public inquiry. There had already been coroners inquests. They said that Article 2 had been infringed.
Held: The . .
Cited – Legal 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:
Cited – Regina v West London Coroner ex parte Gray CA 1988
Before a coroner’s jury could reach a verdict of unlawful killing, it had to be satisfied ‘that the act or omission of a single person must amount to unlawful conduct which was a substantial cause of death’, although Rule 42 of the Coroners Rules . .
Cited – Regina v Wolverhampton Coroner ex parte McCurbin CA 1990
The judicial review test is not simply whether there has been an error of law, but also whether the error has or may have resulted in a wrong verdict being entered. . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – Director 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 . .
Cited – Regina 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 . .
Cited – Regina 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 . .
Cited – Daniel 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 . .
Cited – Regina v South London Coroner ex parte Thompson 8-Jul-1982
The court discussed the function of the coroner and his inquest.
Lord Lane CJ said: ‘The coroner’s task in a case such as this is a formidable one, and no one would dispute that; that is quite apart from the difficulties which inevitably arise . .
Cited – Regina 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

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:
Cited – 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 . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Regina v Coroner for Western District of Sussex Ex Parte Homberg Roberts and Mannerss QBD 27-Jan-1994
A Coroner’s enquires should be as to ‘how’ the death arose, and not into all the circumstances contributing to the death.
Simon Brown LJ said: ‘It is clear that the coroner’s over-riding duty is to inquire ‘how’ the deceased came by his death . .
Cited – Regina v Her Majesty’s Coroner at Hammersmith ex parte Peach CA 1980
A coroner was obliged to sit with a jury under the section 13(2) of the 1926 Act where the deceased, who was watching a demonstration, was struck a violent blow on the back of his head from which he died.
Bridge LJ said: ‘The key to the nature . .
Cited – Regina v 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 . .
Cited – Erikson 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 . .
Cited – Powell v United Kingdom ECHR 4-May-2000
A ten-year old boy had died from Addison’s disease. No inquest took place, because the coroner decided that the boy had died of natural causes. The parents, who were also affected by the events, had accepted compensation from the local health . .
Cited – Salman v Turkey ECHR 27-Jun-2000
Where someone dies or is injured whilst in custody the burden is on the state to provide a ‘satisfactory and convincing explanation’ of what has happened: ‘Persons in custody are in a vulnerable position and the authorities are under a duty to . .
Cited – Regina (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 . .
Cited – Jordan v United Kingdom; McKerr v United Kingdom; similar ECHR 4-May-2001
Proper Investigation of Deaths with Army or Police
Claims were made as regards deaths of alleged terrorists in clashes with the UK armed forces and police. In some cases the investigations necessary to justify the taking of life had been inadequate. Statements made to the inquiry as to the . .
Cited – Calvelli And Ciglio v Italy ECHR 17-Jan-2002
The applicants’ baby had died shortly after birth in 1987. They complained about the medical care. The complaint was not investigated speedily by the authority, resulting in a criminal complaint becoming time barred after a conviction in 1994 was . .
Cited – Edwards v The United Kingdom ECHR 14-Mar-2002
The deceased, a young man of mixed race, had been placed in a cell with another prisoner who was known to be violent, racist, and mentally unstable. The staff knew that the panic button was defective. The deceased was murdered by his cell-mate. His . .
Cited – Amin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
Prisoner’s death – need for full public enquiry
The deceased had been a young Asian prisoner. He was placed in a cell overnight with a prisoner known to be racist, extremely violent and mentally unstable. He was killed. The family sought an inquiry into the death.
Held: There had been a . .
Cited – Goodson v HM Coroner for Bedfordshire and Luton Admn 17-Dec-2004
A patient had died in hospital following an operation. The NHS Trust submitted that ‘There is a real distinction between cases of medical negligence, which were specifically addressed as a discrete area in Calvelli, and cases of intentional killing . .
Cited – Sieminska v Poland ECHR 29-Mar-2001
The applicant’s husband died in hospital, but she later complained that the ambulance had not been equipped with the necessary resuscitation devices. Under Polish law she had a right to appeal against decisions of the prosecuting authorities not to . .
Appeal from – Takoushis, Regina (on the Application of) v HM Coroner for Inner North London Admn 16-Dec-2004
A patient suffering schizophrenia had been a voluntary patient. He was allowed to visit another unit within the hospital grounds, but then left altogether and was next found preparing to jump from Tower Bridge. He was taken by ambulance to Hospital . .

Cited by:
Cited – D, Regina (on the Application of) v Secretary of State for the Home Department (Inquest Intervening) CA 28-Feb-2006
The respondent appealed from orders made as to the conduct of an investigation into an attempted suicide in prison. The judge had severely criticised the appellant’s treatment of the case.
Held: The appeal failed. The court recited the . .
Cited – Cameron 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 . .
Cited – Gentle 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.
Cited – Savage 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 . .
Cited – K 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 . .
Cited – Morrison 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 . .
Cited – Rabone and Another v Pennine Care NHS Trust CA 21-Jun-2010
The claimant’s daughter had committed suicide after being given home leave on a secure ward by the respondent mental hospital. A claim in negligence had been settled, but the parents now appealed refusal of their claim that the hospital had failed . .
Cited – Smith, Regina (on The Application of) v Secretary of State for Defence and Oxfordshire Assistant Deputy Coroner (Equality and Human Rights Commission intervening) SC 30-Jun-2010
The deceased soldier died of heat exhaustion whilst on active service in Iraq. It was said that he was owed a duty under human rights laws, and that any coroner’s inquest should be a fuller one to satisfy the state’s duty under Article 2.
Cited – Birks, 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 . .
Cited – Tyrrell v HM Senior Coroner County Durham and Darlington and Another Admn 26-Jul-2016
The court was aked what article 2 of the European Convention on Human Rights requires of a coroner when a serving prisoner dies of natural causes.
Held: The reuest for judicial review failed. Mr Tyrrell’s death was, from the outset, one which . .

Lists of cited by and citing cases may be incomplete.

Coroners, Human Rights, 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:
Cited – Issa 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 . .
Cited – Bui 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. . .
Cited – Drozd 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 From – 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 . .
At First Instance – Smith 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 – Secretary 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 . .
Cited – Ocalan 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 . .
Cited – Ocalan 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 . .
Cited – Loizidou 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’ . .
Cited – Al 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 . .
Cited – Loizidou 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 . .
Cited – Loizidou 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) . .
Cited – Bankovic 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 . .
Cited – Gentle, Regina (on the Application of) and Another v The Prime Minister and Another HL 9-Apr-2008
The appellants were mothers of two servicemen who had died whilst on active service in Iraq. They appealed refusal to grant a public inquiry. There had already been coroners inquests. They said that Article 2 had been infringed.
Held: The . .
Cited – Carson 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 . .
Cited – X 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 . .
Cited – Stephens 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 . .
Cited – Regina 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 . .
Cited – Cyprus 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 . .
Cited – Gentilhomme, 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 . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – McCann 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 . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Isayeva, 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. . .
Cited – Al-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 . .
Cited – Sacker, Regina (on the Application of) v Coroner for the County of West Yorkshire HL 11-Mar-2004
The deceased committed suicide in prison. Her family sought to have added to the verdict the words ‘contributed by neglect’ and complained that the inquest had not provided a full and proper investigation of the death.
Held: The Act needed to . .
Cited – Nachova 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 . .
Cited – Hurst, Regina (on the Application of) v Commissioner of Police of the Metropolis v London Northern District Coroner HL 28-Mar-2007
The claimant’s son had been stabbed to death. She challenged the refusal of the coroner to continue with the inquest with a view to examining the responsibility of any of the police in having failed to protect him.
Held: The question amounted . .
Cited – Caledonian 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, . .
Cited – Close 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 . .
Cited – Ramsahai 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 . .
Cited – Medvedyev 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 . .
Cited – Calvin’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 . .
Cited – Alcom 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 . .
Cited – Burmah 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 . .
Cited – Nissan 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 . .
Cited – Jones 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 . .
Cited – Littrell 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) . .
Cited – Bici 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 . .
Cited – Holland 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 . .
Cited – Mulcahy 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 . .
Cited – Engel 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 . .
Cited – Soering 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 . .
Cited – Jordan v United Kingdom; McKerr v United Kingdom; similar ECHR 4-May-2001
Proper Investigation of Deaths with Army or Police
Claims were made as regards deaths of alleged terrorists in clashes with the UK armed forces and police. In some cases the investigations necessary to justify the taking of life had been inadequate. Statements made to the inquiry as to the . .
Cited – Carson 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 . .
Cited – Regina 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 . .
Cited – Markovic 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 . .
Cited – Ilascu 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 . .
Cited – Lubbe (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 . .
Cited – Menson v United Kingdom ECHR 6-May-2003
There had been a racist attack. The victim was set on fire and killed in the street by assailants. His relatives sought compensation. However the assailants were not agents of the state and they were duly prosecuted, convicted and sentenced. No . .
Cited – Salman v Turkey ECHR 27-Jun-2000
Where someone dies or is injured whilst in custody the burden is on the state to provide a ‘satisfactory and convincing explanation’ of what has happened: ‘Persons in custody are in a vulnerable position and the authorities are under a duty to . .
Cited – London 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 . .
Cited – Assanidze 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 . .
Cited – Ergi 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 . .
Cited – Savage v South Essex Partnership NHS Foundation Trust (MIND intervening) HL 10-Dec-2008
The deceased had committed suicide on escaping from a mental hospital. The Trust appealed against a refusal to strike out the claim that that they had been negligent in having inadequate security.
Held: The Trust’s appeal failed. The fact that . .
Cited – Byrzykowski v Poland ECHR 27-Jun-2006
. .
Cited – Takoushis, Regina (on the Application of) v HM Coroner for Inner North London and others CA 30-Nov-2005
Relatives sought judicial review of the coroner’s decision not to allow a jury, and against allowance of an expert witness. The deceased had been a mental patient but had been arrested with a view to being hospitalised. He was taken first to the . .
Cited – Akdogdu 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:
Cited – Zagorski 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 . .
Cited – McCaughey and Another, Re Application forJudicial Review SC 18-May-2011
The claimants sought a fuller inquest into deaths at the hands of the British Army in 1990 in Northern Ireland. On opening the inquest, the coroner had declined to undertake to hold a hearing compliant with article 2, and it had not made progress. . .
Cited – Smith 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 . .
Cited – Ambrose 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 . .
Cited – Smith 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 . .
Cited – Long, 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 . .
Cited – Birks, 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 . .
Cited – Letts, Regina (on The Application of) v The Lord Chancellor and Another Admn 20-Feb-2015
Application for judicial review concerning the criteria applied by the Legal Aid Agency to determine whether relatives of a deceased should be granted legal aid for representation at an inquest into a death which has arisen in circumstances which . .
Cited – Kennedy 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 . .
Cited – Sandiford, 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 . .
Cited – Sandiford, 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 . .
Cited – Tyrrell v HM Senior Coroner County Durham and Darlington and Another Admn 26-Jul-2016
The court was aked what article 2 of the European Convention on Human Rights requires of a coroner when a serving prisoner dies of natural causes.
Held: The reuest for judicial review failed. Mr Tyrrell’s death was, from the outset, one which . .
Cited – Commissioner of Police of The Metropolis v DSD and Another SC 21-Feb-2018
Two claimants had each been sexually assaulted by a later notorious, multiple rapist. Each had made complaints to police about their assaults but said that no effective steps had been taken to investigate the serious complaints.
Held: The . .

Lists of cited by and citing cases may be incomplete.

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:
Cited – In the Matter of Captain Christopher John Kelly Admn 14-Jun-1996
The deceased was killed by ‘friendly fire’ during a night exercise in Kenya. A verdict of accidental death was returned, and a fresh inquest was sought particularly in the light of a statement from a fellow officer.
Held: The emergence of . .
Cited – In Re Neal (Coroner: Jury) QBD 17-Nov-1995
The father of the deceased sought to have the coroner quash the inquest. His daughter had died in Spain from carbon monoxide poisoning, apparently emanated from a faulty water heater in the apartment in which she had stayed. Her body had been . .
Cited – Assistant Deputy Coroner of Inner West London v Paul and Another, Regina on the Application of CA 28-Nov-2007
The coroner appealed a judicial review granted after he allowed into evidence, hearsay evidence contained in a written statemnent from a witness who could not attend the inquest.
Held: Rule 37 does not allow the admission of a document, even . .
Cited – Hurst, Regina (on the Application of) v Commissioner of Police of the Metropolis v London Northern District Coroner HL 28-Mar-2007
The claimant’s son had been stabbed to death. She challenged the refusal of the coroner to continue with the inquest with a view to examining the responsibility of any of the police in having failed to protect him.
Held: The question amounted . .
Cited – O’Connor, Regina (On the Application of) v HM Coroner for District of Avon and Another Admn 7-May-2009
Two children died when their father jumped with them from a hotel balcony. The father had been acquitted in Crete of manslaughter after evidence of his psychiatric condition. The applicant now challenged the English coroner’s verdict of unlawful . .
Cited – 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 . .
Approved – McKerr 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 – Secretary 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 from – 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 . .
Cited – Regina v Coroner for Surrey, ex parte Wright 18-Jun-1966
The deceased died when unconscious under general anaesthetic in the course of dental surgery, as a result of an obstruction to his airway.
Held: There was no basis in such circumstances for contending that the verdict of accident should have . .

Cited by:
Cited – Regina (Amin) v Secretary of State for the Home Department; Regina (Middleton) v Coroner for West Somersetshire CA 27-Mar-2002
A prisoner had been killed in his cell by a cell-mate known to be unstable and racist. His family sought to be involved in the inquiry into the death within the prison system. A second prisoner hanged himself in his cell. His family alleged that he . .
Cited – Khan, Regina (on the Application of) v HM Coroner for West Hertfordshire and Another Admn 7-Mar-2002
The deceased died in police custody. The coroner refused to leave to the jury possible verdicts of unlawful killing, or death contributed to by neglect, or breach of his right to life. He adjourned the hearing to allow this challenge.
Held: . .
Cited – Regina on the Application of Mullholland v HM Coroner for St Pancras QBD 7-Nov-2003
The applicant sought to re-open a coroner’s inquest. The deceased had been drunk, slipped banged his head and fallen to the ground. Police and ambulance were called. The ambulance worker was not told he had been unconscious, and he was taken to the . .
Cited – In the Matter of Captain Christopher John Kelly Admn 14-Jun-1996
The deceased was killed by ‘friendly fire’ during a night exercise in Kenya. A verdict of accidental death was returned, and a fresh inquest was sought particularly in the light of a statement from a fellow officer.
Held: The emergence of . .
Cited – Sacker, Regina (on the Application of) v Coroner for the County of West Yorkshire HL 11-Mar-2004
The deceased committed suicide in prison. Her family sought to have added to the verdict the words ‘contributed by neglect’ and complained that the inquest had not provided a full and proper investigation of the death.
Held: The Act needed to . .
Cited – In Re Neal (Coroner: Jury) QBD 17-Nov-1995
The father of the deceased sought to have the coroner quash the inquest. His daughter had died in Spain from carbon monoxide poisoning, apparently emanated from a faulty water heater in the apartment in which she had stayed. Her body had been . .
Cited – In re Catherine Lucy Clegg (an Application to Quash Inquisition on Inquest) Admn 2-Dec-1996
The father of the deceased sought an order quashing the inquest on her death. He had recorded a verdict of suicide. She had died from acute salicylate poisoning, an aspirin overdose. The hospital was said not to have recognised her condition and not . .
Cited – Bloom v HM Assistant Deputy Coroner for the Northern District of London and Another Admn 20-Dec-2004
The deceased had gone to hospital and was diagnosed as having a kidney stone. As it was removed there was evidence of infection. She declined and was transferred to the local NHS hospital in intensive care. She died and a post-mortem identified . .
Cited – LM, 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 . .
Cited – O’Connor, Regina (On the Application of) v HM Coroner for District of Avon and Another Admn 7-May-2009
Two children died when their father jumped with them from a hotel balcony. The father had been acquitted in Crete of manslaughter after evidence of his psychiatric condition. The applicant now challenged the English coroner’s verdict of unlawful . .
Cited – 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 . .
Cited – 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 . .
Cited – Smith, Regina (on The Application of) v Secretary of State for Defence and Oxfordshire Assistant Deputy Coroner (Equality and Human Rights Commission intervening) SC 30-Jun-2010
The deceased soldier died of heat exhaustion whilst on active service in Iraq. It was said that he was owed a duty under human rights laws, and that any coroner’s inquest should be a fuller one to satisfy the state’s duty under Article 2.
Cited – 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 . .
Cited – Kent 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 . .
Cited – Sreedharan, Regina (on The Application of) v HM Coroner for The County of Greater Manchester Admn 28-May-2012
The claimant doctor renewed his application for judicial review of the jury verdict of unlawful killing at the inquest into a patient. The patientwas alcoholic. The doctor prescribed a sedative drug for him, but it was known to be potentially lethal . .
Cited – Tyrrell v HM Senior Coroner County Durham and Darlington and Another Admn 26-Jul-2016
The court was aked what article 2 of the European Convention on Human Rights requires of a coroner when a serving prisoner dies of natural causes.
Held: The reuest for judicial review failed. Mr Tyrrell’s death was, from the outset, one which . .

Lists of cited by and citing cases may be incomplete.

Coroners, 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:
Cited – Gentle, Regina (on the Application of) and Another v The Prime Minister and Another HL 9-Apr-2008
The appellants were mothers of two servicemen who had died whilst on active service in Iraq. They appealed refusal to grant a public inquiry. There had already been coroners inquests. They said that Article 2 had been infringed.
Held: The . .
Cited – Secretary 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 . .
Cited – Bankovic 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 . .
Cited – Drozd 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 . .
Cited – Soering 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 . .
Cited – Cyprus 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 . .
Cited – Al-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 . .
Cited – Engel 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 . .
Cited – Issa 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 . .
Cited – Regina 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 from – Smith 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 From – 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.
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 Instance – Maughan, 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 from – 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 . .

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:
Cited – Jordan v United Kingdom; McKerr v United Kingdom; similar ECHR 4-May-2001
Proper Investigation of Deaths with Army or Police
Claims were made as regards deaths of alleged terrorists in clashes with the UK armed forces and police. In some cases the investigations necessary to justify the taking of life had been inadequate. Statements made to the inquiry as to the . .
Cited – In re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
Cited – Edwards v The United Kingdom ECHR 14-Mar-2002
The deceased, a young man of mixed race, had been placed in a cell with another prisoner who was known to be violent, racist, and mentally unstable. The staff knew that the panic button was defective. The deceased was murdered by his cell-mate. His . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Soering 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 . .
Cited – Secretary 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 . .
Cited – Regina 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 instance – Gentle and Others, Regina (on the Application of) v the Prime Minister and others Admn 20-Dec-2005
The applicants sought leave to bring judicial review of the decisions which led to the invasion of Iraq. They were relatives of servicemen who had died there.
Held: The court’s only duty at this stage was to ask whether there was an arguable . .
Appeal from – Regina (on the appication of Gentle and Clarke) v The Prime Minister; Secretary of Sate for Defence; Attornery General CA 12-Dec-2006
The mothers of two servicemen who had died whilst on service in the war in Iraq challenged refusal to hold an independent inquiry into the circumstances leading to the invasion of Iraq.
Held: The appeal failed. . .
Cited – Buttes 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 . .
Cited – Council 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 . .
Cited – Regina 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 . .
Cited – JH 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 . .
Cited – Regina (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 . .
Cited – Takoushis, Regina (on the Application of) v HM Coroner for Inner North London Admn 16-Dec-2004
A patient suffering schizophrenia had been a voluntary patient. He was allowed to visit another unit within the hospital grounds, but then left altogether and was next found preparing to jump from Tower Bridge. He was taken by ambulance to Hospital . .
Cited – Regina v Lyons, Parnes, Ronson, Saunders HL 15-Nov-2002
The defendants had been convicted on evidence obtained from them by inspectors with statutory powers to require answers on pain of conviction. Subsequently the law changed to find such activity an infringement of a defendant’s human rights.
Cited – Campaign 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 . .
Cited – Bubbins v United Kingdom ECHR 17-Mar-2005
The deceased had returned home drunk, and climbed in through a window. His girlfriend saw only his legs and reported an intruder to the police. He refused to identify himself when challenged by the police and on pointing a gun from the window he was . .
Cited – Engel 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 . .
Cited – Taylor v United Kingdom ECHR 1994
. .
Cited – Banks 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 . .
Cited – Scholes 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 . .
Cited – McShane v The United Kingdom ECHR 28-May-2002
HER Judgment (Merits and just satisfaction) Violation of Art. 2; No violation of Art. 6-1; No violation of Art. 14; No violation of Art. 13; Failure to comply with obligations under Article 34
The deceased . .
Cited – Grigoriades 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 . .
Cited – McBride v United Kingdom ECHR 2006
. .
Cited – Stott (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:
Cited – Smith 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 – Corner 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 . .
Cited – 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 . .
Cited – Smith, Regina (on The Application of) v Secretary of State for Defence and Oxfordshire Assistant Deputy Coroner (Equality and Human Rights Commission intervening) SC 30-Jun-2010
The deceased soldier died of heat exhaustion whilst on active service in Iraq. It was said that he was owed a duty under human rights laws, and that any coroner’s inquest should be a fuller one to satisfy the state’s duty under Article 2.
Cited – Smith 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 . .
Cited – Lord 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 . .
Cited – Shergill 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. . .
Cited – Letts, Regina (on The Application of) v The Lord Chancellor and Another Admn 20-Feb-2015
Application for judicial review concerning the criteria applied by the Legal Aid Agency to determine whether relatives of a deceased should be granted legal aid for representation at an inquest into a death which has arisen in circumstances which . .
Cited – Tyrrell v HM Senior Coroner County Durham and Darlington and Another Admn 26-Jul-2016
The court was aked what article 2 of the European Convention on Human Rights requires of a coroner when a serving prisoner dies of natural causes.
Held: The reuest for judicial review failed. Mr Tyrrell’s death was, from the outset, one which . .

Lists of cited by and citing cases may be incomplete.

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:
Cited – 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 . .
Cited – Longfield Care Homes Ltd, Regina (on the Application Of) v HM Coroner for Blackburn and others Admn 14-Oct-2004
An elderly lady had died after falling from an open window at her care home. Although she suffered moderately severe injuries from the fall, they were not serious enough of themselves to cause her death which resulted from pre-existing pneumonia, . .

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:
Cited – Regina 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 . .
Cited – Land 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 . .
Cited – In Re T (Adult: Refusal of Treatment) CA 30-Jul-1992
Appeal with regard to a right as to how the claimant should live. . .
Cited – Regina 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 . .
Cited – HE 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

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:
Cited – Bloom v HM Assistant Deputy Coroner for the Northern District of London and Another Admn 20-Dec-2004
The deceased had gone to hospital and was diagnosed as having a kidney stone. As it was removed there was evidence of infection. She declined and was transferred to the local NHS hospital in intensive care. She died and a post-mortem identified . .
Cited – Regina v HM Coroner, Lincoln, ex parte Hay 19-Feb-1987
. .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – Regina v 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 . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – 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 . .

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 From – Lewis, Regina (On the Application of) v HM Coroner for the Mid and North Division Of the County Of Shropshire and Another Admn 3-Apr-2009
. .
Cited – Oneryildiz v Turkey ECHR 30-Nov-2004
(Grand Chamber) The applicant had lived with his family in a slum bordering on a municipal household refuse tip. A methane explosion at the tip resulted in a landslide which engulfed the applicant’s house killing his close relatives.
Held: The . .
Cited – Sacker, Regina (on the Application of) v Coroner for the County of West Yorkshire HL 11-Mar-2004
The deceased committed suicide in prison. Her family sought to have added to the verdict the words ‘contributed by neglect’ and complained that the inquest had not provided a full and proper investigation of the death.
Held: The Act needed to . .
Cited – Allen, Regina (On the Application of) v Coroner for Inner North London CA 25-Jun-2009
. .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
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 from – Regina 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:
Cited – Shafi v HM Senior Coroner for East London Admn 20-Jul-2015
The claimant’s son had died in a prison attached to a police station in Dubai. She sought a new inquest saying that the first had been inadequate.
Held: A new inquest was ordered. There had been difficulties in that the Dubai authorities had . .

Lists of cited by and citing cases may be incomplete.

Coroners

Leading Case

Updated: 01 November 2021; Ref: scu.254559

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:
Cited – Regina v South London Coroner ex parte Thompson 8-Jul-1982
The court discussed the function of the coroner and his inquest.
Lord Lane CJ said: ‘The coroner’s task in a case such as this is a formidable one, and no one would dispute that; that is quite apart from the difficulties which inevitably arise . .
Cited – Regina 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 . .
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – Appleby, 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 . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Coroners, Road Traffic

Updated: 01 November 2021; Ref: scu.464820

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:
Cited – Rex v Saunders 1719
. .
See Also – 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: . .
Cited – Reed 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:
Cited – 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 . .

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 also – In re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .

Cited by:
Cited – Regina (Amin) v Secretary of State for the Home Department QBD 5-Oct-2001
An Asian youth was placed in a cell with another who was well known to be violent and racist. He was bludgeoned to death. The family sought a public investigation into how he came to be placed in such a position. An investigation had been refused by . .
Cited – Khan, Regina (on the Application of) v Secretary of State for Health CA 10-Oct-2003
The claimant’s child had died as a result of negligence in hospital. The parents had been told the result of police investigation and decision not to prosecute, and the hospital’s own investigation, but had not been sufficiently involved. There . .
Cited – Amin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
Prisoner’s death – need for full public enquiry
The deceased had been a young Asian prisoner. He was placed in a cell overnight with a prisoner known to be racist, extremely violent and mentally unstable. He was killed. The family sought an inquiry into the death.
Held: There had been a . .
Cited – Regina (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 Also – In re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – Mullen, 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 . .
Cited – Three 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 . .
Cited – Regina 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: . .
Cited – D, Regina (on the Application of) v Secretary of State for the Home Department Admn 28-Apr-2005
D was undergoing trial for offences and was held in prison. He self-harmed repeatedly, and was recorded to require extra vigilance. He attempted to hang himself. Prison staff saved his life, but he was left paraplegic, and was then detained under . .
Cited – Takoushis, Regina (on the Application of) v HM Coroner for Inner North London and others CA 30-Nov-2005
Relatives sought judicial review of the coroner’s decision not to allow a jury, and against allowance of an expert witness. The deceased had been a mental patient but had been arrested with a view to being hospitalised. He was taken first to the . .
Cited – D, Regina (on the Application of) v Secretary of State for the Home Department (Inquest Intervening) CA 28-Feb-2006
The respondent appealed from orders made as to the conduct of an investigation into an attempted suicide in prison. The judge had severely criticised the appellant’s treatment of the case.
Held: The appeal failed. The court recited the . .
Cited – Gentle, Regina (on the Application of) and Another v The Prime Minister and Another HL 9-Apr-2008
The appellants were mothers of two servicemen who had died whilst on active service in Iraq. They appealed refusal to grant a public inquiry. There had already been coroners inquests. They said that Article 2 had been infringed.
Held: The . .
Cited – Smith 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 – JL, Regina (on the Application of) v Secretary of State for Justice; Regina (L (A Patient)) v Secretary of State for the Home Department HL 26-Nov-2008
The prisoner was left with serious injury after attempting suicide in prison. He said that there was a human rights duty to hold an investigation into the circumstances leading up to this.
Held: There existed a similar duty to hold an enhanced . .
Cited – Morrison 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 Also – McKerr v United Kingdom; Action of the Security Forces in Northern Ireland ECHR 17-Apr-2009
. .
Cited – Smith, Regina (on The Application of) v Secretary of State for Defence and Oxfordshire Assistant Deputy Coroner (Equality and Human Rights Commission intervening) SC 30-Jun-2010
The deceased soldier died of heat exhaustion whilst on active service in Iraq. It was said that he was owed a duty under human rights laws, and that any coroner’s inquest should be a fuller one to satisfy the state’s duty under Article 2.
Cited – SG 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 . .
Cited – Tyrrell v HM Senior Coroner County Durham and Darlington and Another Admn 26-Jul-2016
The court was aked what article 2 of the European Convention on Human Rights requires of a coroner when a serving prisoner dies of natural causes.
Held: The reuest for judicial review failed. Mr Tyrrell’s death was, from the outset, one which . .

Lists of cited by and citing cases may be incomplete.

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:
Cited – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Cited – In re Rapier (Deceased) QBD 1988
A young prisoner had been found dead in his cell hanging. A report suggested that he may have been sniffing solvents. The coroner himself initiated proceedings both under the Coroners’ Act and for judicial review to quash the inquisition over which . .
Cited – O’Reilly v Coventry Coroner QBD 3-Apr-1996
The inquest was said to have been flawed because relevant material was withheld from the jury, factual issues were not addressed, and the Coroner had refused to leave open the possibility of a verdict of lack of care or neglect. The deceased had . .

Cited by:
Cited – 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 . .

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:
Cited – Regina v HM Coroner for Exeter and East Devon ex parte Palmer 10-Dec-1997
Lord Woolf discussed the role of the coroner acting as a filter to avoid injustice: ‘In a difficult case, the Coroner is carrying out an evaluation exercise. He is looking at the evidence before him as a whole and saying to himself, without deciding . .

Cited by:
Cited – Bennett, Regina (on the Application of) v HM Coroner for Inner South London and others CA 26-Jun-2007
The deceased had been shot by the police, who mistakenly believed him to be armed. Judicial review was sought saying that the coroner had wrongly refused to leave to the jury the possible verdict of unlawful killing.
Held: The appeal was . .

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

Lists of cited by and citing cases may be incomplete.
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 to – Regina on the Application Of Christine Davies v HM Deputy Coroner for Birmingham CA 2-Dec-2003
. .

Cited by:
Appeal from – Regina 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 from – Regina 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 to – McKerr 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:
Cited – In re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
Cited – Assistant Deputy Coroner of Inner West London v Paul and Another, Regina on the Application of CA 28-Nov-2007
The coroner appealed a judicial review granted after he allowed into evidence, hearsay evidence contained in a written statemnent from a witness who could not attend the inquest.
Held: Rule 37 does not allow the admission of a document, even . .
Cited – Regina 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