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
Coroners Rules 1984 (SI 1984 No 552) 43
England and Wales
Appeal FromLewis, Regina (On the Application of) v HM Coroner for the Mid and North Division Of the County Of Shropshire and Another Admn 3-Apr-2009
. .
CitedOneryildiz v Turkey ECHR 30-Nov-2004
(Grand Chamber) The applicant had lived with his family in a slum bordering on a municipal household refuse tip. A methane explosion at the tip resulted in a landslide which engulfed the applicant’s house killing his close relatives.
Held: The . .
CitedSacker, Regina (on the Application of) v Coroner for the County of West Yorkshire HL 11-Mar-2004
The deceased committed suicide in prison. Her family sought to have added to the verdict the words ‘contributed by neglect’ and complained that the inquest had not provided a full and proper investigation of the death.
Held: The Act needed to . .
CitedAllen, Regina (On the Application of) v Coroner for Inner North London CA 25-Jun-2009
. .
CitedMiddleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Coroners, Human Rights

Leading Case

Updated: 01 November 2021; Ref: scu.392510