A Coroner’s enquires should be as to ‘how’ the death arose, and not into all the circumstances contributing to the death.
Simon Brown LJ said: ‘It is clear that the coroner’s over-riding duty is to inquire ‘how’ the deceased came by his death and that duty prevails over any inhibition against appearing to determine questions of criminal or civil liability . . Secondly, the cases establish that although the is word ‘how’ is to be widely interpreted, it means ‘by what means’ rather than ‘in what broad circumstances’ . . In short the inquiry must focus on matters directly causative of death and must indeed, be confined to these matters alone (save for ascertainment of the other specific details mentioned in r36(1)). The recent, 11th edition of Jervis on Coroners puts it like this: ‘The question of how the deceased came by his death is of course wider than merely finding the principal cause of death, and it is therefore right and proper that the coroner should inquire into acts and omissions which are directly responsible for the death.’ and ‘The duty to inquire ‘how’ the deceased dies does not to my mind properly encompass inquiry also into the underlying responsibility for every circumstance which may be said to have contributed to the death.’
‘It is the duty of the coroner as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the facts are fully, fairly and fearlessly investigated. He is bound to recognise the acute public concern rightly aroused when deaths occur in custody. He must ensure that the relevant facts are exposed to public scrutiny, particularly if there is evidence of foul play, abuse or inhumanity. He fails in his duty if his investigation is superficial, slipshod or perfunctory. But the responsibility is his. He must set the bounds of the inquiry.’
Morland J ‘In my judgment the purpose of such a jury inquest under s8(3)(d) is clear. It is so that lessons can be learned from the circumstanmces of the death so that in future the risk of injuries to health and safety arising from similar circiumstances should be prevented or reduced.’
Simon Brown LJ, Morland J
Independent 27-Jan-1994, (1994) 158 JP 357
Coroners Rules 1984 36(1)
England and Wales
Cited by:
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 – Middleton, Regina (on the Application of) v Coroner for the Western District of Somerset Admn 14-Dec-2001
The deceased had committed suicide whilst in prison. It was argued that the prison should have recognised that he was a suicide risk, and acted accordingly. The coroner had requested a note from the jury as to the cause of death. The court . .
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 – 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 – 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 . .
Lists of cited by and citing cases may be incomplete.
Updated: 07 August 2021; Ref: scu.86442 br>