Regina v Poplar Coroner ex parte Thomas: CA 15 Dec 1992

The deceased, aged 17, had had a severe asthma attack. The ambulance was delayed and she was taken to the hospital, but died on the way there despite assistance from police officers and latterly the ambulance staff. Evidence suggested that she might have survived if she had been got to the hospital earlier, but the cause of death was the asthma attack. The family challenged the failure to hold an inquest. The divisional court held the death may have been unnatural, and that the public interest required an inquest.
Held: The coroner did not have a discretion about holding an inquest only because of the public interest. His duty was set out in the Act. He was wrong to preclude himself from investigating a death from lack of care. It was important to have consistency in decisions about whether to hold inquests. The word ‘unnatural’ in the section should be given its ordinary meaning and that the question of natural or unnatural depended on the cause of death and that this was essentially a practical question of fact. The circumstances surrounding the death may turn what might otherwise be a natural death into an unnatural one. Simon Brown LJ: ‘I agree that unnatural is an ordinary word of the English language and that there is nothing to suggest that in S8(1) of the Coroners Act 1988 it is being used in any unusual sense. That, however, is not to say that whether or not a particular death is properly to be regarded as unnatural is a pure question of fact. On the contrary it seems to me that some guidance at least can and should be given as a matter of law by the Courts to Coroners so that they may focus their attention upon the real considerations material to the decision and, one hopes, thereby achieve an essential measure of consistency in their approach to the section.’ and ‘Merely, however, because the Coroner’s inquest may nowadays may be though lacking any very clear or cogent role is no sufficient reason for adopting too narrow an approach to S.8. I repeat, it seems to me necessary to recognise that cases may well arise in which human fault can and properly should be found to turn what would otherwise be a natural death into an unnatural one, and into which, therefore, an inquest should be held.’ Dillon LJ: ` . . it is not the function of a coroner’s inquest to provide a forum for attempts to gather evidence for pending or future criminal or civil proceedings.’


Simon Brown LJ, Dillon LJ, Farquharson LJ


Gazette 10-Jun-1992, [1993] QB 610, [1993] 2 ALL ER 381, [1993] 2 WLR 547, Times 23-Dec-1992, Independent 20-Jan-1992, (1993) 157 JP 506, [1993] COD 178, (1993) 157 JPN 349


Coroners Act 1988 88(1)


England and Wales

Cited by:

CitedIndependent Assessor v O’Brien, Hickey, Hickey CA 29-Jul-2004
The claimants had been imprisoned for many years before their convictions were quashed. They claimed compensation under the Act. The assessor said that there should be deducted from the award the living expenses they would have incurred if they had . .
CitedRegina v Coroner for Southern District of Greater London, ex Parte Driscoll Admn 22-Oct-1993
The applicant, a sister of the deceased, requested a judicial review of the decision of the coroner not to allow her to be represented and to cross examine witnesses.
Held: One of the coroner’s letters had been offensive and misleading. A . .
CitedRegina v Her Majesty’s Coroner for District of Avon ex parte Smith Admn 12-Feb-1998
The family sought judicial review of a decision not to hold an inquest into the death of the deceased. The child had died in hospital.
Held: The death had apparently been for natural causes, but the coroner had failed properly to ask himself . .
Lists of cited by and citing cases may be incomplete.


Updated: 07 February 2022; Ref: scu.224128