Greenough v Ministry of Justice: Admn 11 Sep 2013

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

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

Coroners, Legal Aid

Updated: 22 November 2021; Ref: scu.516590

Sutovic, Regina (on the Application Of) v HM Coroner for North London: Admn 17 May 2006

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

Moses LJ, Beatson J
[2006] EWHC 1095 (Admin)
Bailii
Coroners Act 1988 13
England and Wales
Citing:
CitedRegina v HM Coroner, Lincoln, ex parte Hay 19-Feb-1987
. .
CitedIn re Rapier (Deceased) QBD 1988
A young prisoner had been found dead in his cell hanging. A report suggested that he may have been sniffing solvents. The coroner himself initiated proceedings both under the Coroners’ Act and for judicial review to quash the inquisition over which . .

Cited by:
See AlsoHM Coroner for the Eastern District of London, Regina (On the Application of) v Sutovic Admn 31-Jul-2009
The deceased had died in Serbia, but was buried in Acton. A second inquest had been ordered on the request of the respondent, and an exhumation licence granted for the purposes of a second post mortem examination. The respondent had refused her . .

Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 17 November 2021; Ref: scu.241780

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

Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson: CA 27 Apr 1994

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

Sir Thomas Bingham MR
Times 28-Apr-1994, Independent 27-Apr-1994, [1995] QB 1, [1994] 3 All ER 972, [1994] 3 WLR 82, (1994) 158 JP 1011;, (1994) 19 BMLR 35
Coroners Act 1988 11(5)(b)(ii), Coroners Rules 1984 36(1) 40
England and Wales
Citing:
Appeal fromRegina v North Humberside and Scunthorpe Coroner ex parte Jamieson QBD 12-Jul-1993
northhumberside_jamiesonCA1993
A prisoner had hanged himself after being left unsupervised in a single cell. He was a known suicide risk, but the Coroner directed the jury not to return a verdict which included any reference to lack of care.
Held: A coroner was free not to . .
CitedRegina v Coroner for Surrey, ex parte Wright 18-Jun-1966
The deceased died when unconscious under general anaesthetic in the course of dental surgery, as a result of an obstruction to his airway.
Held: There was no basis in such circumstances for contending that the verdict of accident should have . .

Cited by:
CitedRegina (Amin) v Secretary of State for the Home Department; Regina (Middleton) v Coroner for West Somersetshire CA 27-Mar-2002
A prisoner had been killed in his cell by a cell-mate known to be unstable and racist. His family sought to be involved in the inquiry into the death within the prison system. A second prisoner hanged himself in his cell. His family alleged that he . .
CitedKhan, Regina (on the Application of) v HM Coroner for West Hertfordshire and Another Admn 7-Mar-2002
The deceased died in police custody. The coroner refused to leave to the jury possible verdicts of unlawful killing, or death contributed to by neglect, or breach of his right to life. He adjourned the hearing to allow this challenge.
Held: . .
CitedRegina on the Application of Mullholland v HM Coroner for St Pancras QBD 7-Nov-2003
The applicant sought to re-open a coroner’s inquest. The deceased had been drunk, slipped banged his head and fallen to the ground. Police and ambulance were called. The ambulance worker was not told he had been unconscious, and he was taken to the . .
CitedIn the Matter of Captain Christopher John Kelly Admn 14-Jun-1996
The deceased was killed by ‘friendly fire’ during a night exercise in Kenya. A verdict of accidental death was returned, and a fresh inquest was sought particularly in the light of a statement from a fellow officer.
Held: The emergence of . .
CitedSacker, Regina (on the Application of) v Coroner for the County of West Yorkshire HL 11-Mar-2004
The deceased committed suicide in prison. Her family sought to have added to the verdict the words ‘contributed by neglect’ and complained that the inquest had not provided a full and proper investigation of the death.
Held: The Act needed to . .
CitedIn Re Neal (Coroner: Jury) QBD 17-Nov-1995
The father of the deceased sought to have the coroner quash the inquest. His daughter had died in Spain from carbon monoxide poisoning, apparently emanated from a faulty water heater in the apartment in which she had stayed. Her body had been . .
CitedIn re Catherine Lucy Clegg (an Application to Quash Inquisition on Inquest) Admn 2-Dec-1996
The father of the deceased sought an order quashing the inquest on her death. He had recorded a verdict of suicide. She had died from acute salicylate poisoning, an aspirin overdose. The hospital was said not to have recognised her condition and not . .
CitedBloom v HM Assistant Deputy Coroner for the Northern District of London and Another Admn 20-Dec-2004
The deceased had gone to hospital and was diagnosed as having a kidney stone. As it was removed there was evidence of infection. She declined and was transferred to the local NHS hospital in intensive care. She died and a post-mortem identified . .
CitedLM, Re (Reporting Restrictions; Coroner’s Inquest) FD 1-Aug-2007
A child had died. In earlier civil proceedings, the court had laid responsibility with the mother. Restrictions had been placed on the information which would effectively prevent the coroner conducting his inquest. The coroner sought a lifting of . .
CitedO’Connor, Regina (On the Application of) v HM Coroner for District of Avon and Another Admn 7-May-2009
Two children died when their father jumped with them from a hotel balcony. The father had been acquitted in Crete of manslaughter after evidence of his psychiatric condition. The applicant now challenged the English coroner’s verdict of unlawful . .
CitedP, Regina (on The Application of) v HM Coroner for The District of Avon CA 18-Dec-2009
The deceased was found hanging in her prison cell. The jury returned a verdict of accidental death, not being satisfied that she was not merely making a cry for help. The family appealed a finding that the inquest had satisfied the requirement for a . .
CitedJones v HM Coroner for The Southern District of Greater London and Another Admn 28-Apr-2010
The mother of the deceased asked for a new inquest, saying that there had been insufficient enquiry. He was an adult suffering Asperger’s syndrome and other difficulties, but had sought and been given excess prescriptions of fentanyl a drug to . .
CitedSmith, Regina (on The Application of) v Secretary of State for Defence and Oxfordshire Assistant Deputy Coroner (Equality and Human Rights Commission intervening) SC 30-Jun-2010
The deceased soldier died of heat exhaustion whilst on active service in Iraq. It was said that he was owed a duty under human rights laws, and that any coroner’s inquest should be a fuller one to satisfy the state’s duty under Article 2.
CitedWilkinson, Regina (on The Application of) v HM Coroner for The Greater Manchester South District Admn 11-Oct-2012
The court was asked whether evidence of the commission of the criminal offence of causing death by careless driving contrary to section 2B of the 1988 Act is capable of justifying a verdict of ‘unlawful killing’ at an inquest.
Held: The . .
CitedKent County Council, Regina (on The Application of) v HM Coroner for The County of Kent (North-West District) and Others Admn 15-Oct-2012
The council sought review of the coroner’s decision that the inquest would be an article 2 inquest and with a jury. The deceased was 14 years old and had taken methadone. In the months before his death, he had had involvement with the council’s . .
CitedSreedharan, Regina (on The Application of) v HM Coroner for The County of Greater Manchester Admn 28-May-2012
The claimant doctor renewed his application for judicial review of the jury verdict of unlawful killing at the inquest into a patient. The patientwas alcoholic. The doctor prescribed a sedative drug for him, but it was known to be potentially lethal . .
CitedTyrrell v HM Senior Coroner County Durham and Darlington and Another Admn 26-Jul-2016
The court was aked what article 2 of the European Convention on Human Rights requires of a coroner when a serving prisoner dies of natural causes.
Held: The reuest for judicial review failed. Mr Tyrrell’s death was, from the outset, one which . .

Lists of cited by and citing cases may be incomplete.

Coroners, Health Professions, Prisons

Leading Case

Updated: 01 November 2021; Ref: scu.87444

Gentle, Regina (on the Application of) and Another v The Prime Minister and Another: HL 9 Apr 2008

The appellants were mothers of two servicemen who had died whilst on active service in Iraq. They appealed refusal to grant a public inquiry. There had already been coroners inquests. They said that Article 2 had been infringed.
Held: The appeal was dismissed. The right to an inquiry was procedural and depended first on the claimants establishing an arguable case that the substantive right was infringed. There would be no ability at common law to require such and inquiry, and no obligation was to be created through human rights law.
The issue was however justiciable. Baroness Hale said: ‘it is now common ground that if a Convention right requires the court to examine and adjudicate upon matters which were previously regarded as non-justiciable, then adjudicate we must.’
Lord Bingham of Cornhill observed: ‘issues which judicial tribunals have traditionally been very reluctant to entertain because they recognise their limitations as suitable bodies to resolve them. This is not to say that if the claimants have a legal right the courts cannot decide it. The defendants accept that if the claimants have a legal right it is justiciable in the courts, and they do not seek to demarcate areas into which the courts may not intrude.’

Lord Bingham of Cornhill, Lord Hoffmann, Lord Hope of Craighead, Lord Scott of Foscote, Lord Rodger of Earlsferry, Baroness Hale of Richmond, Lord Carswell, Lord Brown of Eaton-under-Heywood, Lord Mance
[2008] UKHL 20, Times 10-Apr-2008, [2008] 2 WLR 879, [2008] 1 AC 1356, [2008] UKHRR 822, [2008] HRLR 27, [2008] 3 All ER 1
Bailii, HL
European Convention on Human Rights 2 3
England and Wales
Citing:
CitedJordan v United Kingdom; McKerr v United Kingdom; similar ECHR 4-May-2001
Proper Investigation of Deaths with Army or Police
Claims were made as regards deaths of alleged terrorists in clashes with the UK armed forces and police. In some cases the investigations necessary to justify the taking of life had been inadequate. Statements made to the inquiry as to the . .
CitedIn re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
CitedEdwards v The United Kingdom ECHR 14-Mar-2002
The deceased, a young man of mixed race, had been placed in a cell with another prisoner who was known to be violent, racist, and mentally unstable. The staff knew that the panic button was defective. The deceased was murdered by his cell-mate. His . .
CitedMiddleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
CitedSoering v The United Kingdom ECHR 7-Jul-1989
(Plenary Court) The applicant was held in prison in the UK, pending extradition to the US to face allegations of murder, for which he faced the risk of the death sentence, which would be unlawful in the UK. If extradited, a representation would be . .
CitedSecretary of State for Defence v Al-Skeini and others (The Redress Trust Intervening) HL 13-Jun-2007
Complaints were made as to the deaths of six Iraqi civilians which were the result of actions by a member or members of the British armed forces in Basra. One of them, Mr Baha Mousa, had died as a result of severe maltreatment in a prison occupied . .
CitedRegina v Jones (Margaret), Regina v Milling and others HL 29-Mar-2006
Domestic Offence requires Domestic Defence
Each defendant sought to raise by way of defence of their otherwise criminal actions, the fact that they were attempting to prevent the commission by the government of the crime of waging an aggressive war in Iraq, and that their acts were . .
At first instanceGentle and Others, Regina (on the Application of) v the Prime Minister and others Admn 20-Dec-2005
The applicants sought leave to bring judicial review of the decisions which led to the invasion of Iraq. They were relatives of servicemen who had died there.
Held: The court’s only duty at this stage was to ask whether there was an arguable . .
Appeal fromRegina (on the appication of Gentle and Clarke) v The Prime Minister; Secretary of Sate for Defence; Attornery General CA 12-Dec-2006
The mothers of two servicemen who had died whilst on service in the war in Iraq challenged refusal to hold an independent inquiry into the circumstances leading to the invasion of Iraq.
Held: The appeal failed. . .
CitedButtes Gas and Oil Co v Hammer (No 3) HL 1981
In a defamation action, issues arose as to two conflicting oil concessions which neighbouring states in the Arabian Gulf had granted over their territorial and offshore waters. The foreign relations of the United Kingdom and Iran were also involved . .
CitedCouncil of Civil Service Unions v Minister for the Civil Service HL 22-Nov-1984
Exercise of Prerogative Power is Reviewable
The House considered an executive decision made pursuant to powers conferred by a prerogative order. The Minister had ordered employees at GCHQ not to be members of trades unions.
Held: The exercise of a prerogative power of a public nature . .
CitedRegina v Foreign Secretary ex parte Everett CA 20-Oct-1988
A decision taken under the royal prerogative whether or not to issue a passport was subject to judicial review, although relief was refused on the facts of the particular case.
Taylor LJ summarised the effect of the GCHQ case as making clear . .
CitedJH Rayner (Mincing Lane) Ltd v Department of Trade and Industry HL 1989
An undisclosed principal will not be permitted to claim to be party to a contract if this is contrary to the terms of the contract itself. Thus the provision in the standard form B contract of the London Metal Exchange ‘this contract is made between . .
CitedRegina (Abbasi) v Secretary of State for Foreign Affairs CA 6-Nov-2002
There is no authority in law to support the imposition of an enforceable duty on the state to protect the citizen, and although the court was able to intervene, in limited ways, in the way in which the Foreign and Commonwealth Office used its . .
CitedTakoushis, Regina (on the Application of) v HM Coroner for Inner North London Admn 16-Dec-2004
A patient suffering schizophrenia had been a voluntary patient. He was allowed to visit another unit within the hospital grounds, but then left altogether and was next found preparing to jump from Tower Bridge. He was taken by ambulance to Hospital . .
CitedRegina v Lyons, Parnes, Ronson, Saunders HL 15-Nov-2002
The defendants had been convicted on evidence obtained from them by inspectors with statutory powers to require answers on pain of conviction. Subsequently the law changed to find such activity an infringement of a defendant’s human rights.
CitedCampaign for Nuclear Disarmament (CND) v Prime Minister and others Admn 17-Dec-2002
CND sought an advisory declaration as to the meaning of UN Security Council resolution 1441, which had given Iraq ‘a final opportunity to comply with its disarmament obligations’ and whether the resolution authorised states to take military action . .
CitedBubbins v United Kingdom ECHR 17-Mar-2005
The deceased had returned home drunk, and climbed in through a window. His girlfriend saw only his legs and reported an intruder to the police. He refused to identify himself when challenged by the police and on pointing a gun from the window he was . .
CitedEngel And Others v The Netherlands (1) ECHR 8-Jun-1976
engel_netherlandsECHR1976
The court was asked whether proceedings in a military court against soldiers for disciplinary offences involved criminal charges within the meaning of Article 6(1): ‘In this connection, it is first necessary to know whether the provision(s) defining . .
CitedTaylor v United Kingdom ECHR 1994
. .
CitedBanks v United Kingdom ECHR 6-Feb-2007
The applicants complained of maltreatment by prison officers in breach of article 3. The matter had been investigated by the Crown Prosecution Service which had decided not to prosecute. Civil proceedings had been raised and settled. The applicants . .
CitedScholes v Secretary of State for the Home Department CA 17-Oct-2006
The deceased had committed suicide whilst in prison. The judge had requested that prison should be told of the risk of self harm. The mother appealed refusal of the judge to grant a judicial review of the Home Secretary’s refusal to grant, as . .
CitedMcShane v The United Kingdom ECHR 28-May-2002
HER Judgment (Merits and just satisfaction) Violation of Art. 2; No violation of Art. 6-1; No violation of Art. 14; No violation of Art. 13; Failure to comply with obligations under Article 34
The deceased . .
CitedGrigoriades v Greece ECHR 25-Nov-1997
Hudoc Judgment (Merits and just satisfaction) Violation of Art. 10; No violation of Art. 7; Non-pecuniary damage – finding of violation sufficient; Costs and expenses partial award – Convention proceedings . .
CitedMcBride v United Kingdom ECHR 2006
. .
CitedStott (Procurator Fiscal, Dunfermline) and Another v Brown PC 5-Dec-2000
The system under which the registered keeper of a vehicle was obliged to identify herself as the driver, and such admission was to be used subsequently as evidence against her on a charge of driving with excess alcohol, was not a breach of her right . .

Cited by:
CitedSmith v The Assistant Deputy Coroner for Oxfordshire Admn 11-Apr-2008
The claimant’s son had died of hyperthermia whilst serving in the army in Iraq. The parties requested a new inquisition after the coroner had rules that human rights law did not apply to servicemen serving outside Europe. Reports had been prepared . .
CitedCorner House Research and Others, Regina (on the Application of) v The Serious Fraud Office HL 30-Jul-2008
SFO Director’s decisions reviewable
The director succeeded on his appeal against an order declaring unlawful his decision to discontinue investigations into allegations of bribery. The Attorney-General had supervisory duties as to the exercise of the duties by the Director. It had . .
CitedSecretary of State for Defence v Smith, Regina (on the Application of) CA 18-May-2009
The soldier had died of heatstroke after exercises in Iraq. The Minister appealed against a finding that the circumstances of his death required an investigation compliant with Article 2 human rights, saying that he was not subject to such . .
CitedSmith, Regina (on The Application of) v Secretary of State for Defence and Oxfordshire Assistant Deputy Coroner (Equality and Human Rights Commission intervening) SC 30-Jun-2010
The deceased soldier died of heat exhaustion whilst on active service in Iraq. It was said that he was owed a duty under human rights laws, and that any coroner’s inquest should be a fuller one to satisfy the state’s duty under Article 2.
CitedSmith and Others v The Ministry of Defence SC 19-Jun-2013
The claimants were PRs of men who had died or were severely injured on active duty in Iraq being variously fired at by mistake by other coalition forces, or dying in vehicles attacked by roadside bombs. Appeals were heard against a finding that the . .
CitedLord Carlile of Berriew QC, and Others, Regina (on The Application of) v Secretary of State for The Home Department SC 12-Nov-2014
The claimant had supported the grant of a visa to a woman in order to speak to members of Parliament who was de facto leader of an Iranian organsation which had in the past supported terrorism and had been proscribed in the UK, but that proscription . .
CitedShergill and Others v Khaira and Others SC 11-Jun-2014
The parties disputed the trusts upon which three Gurdwaras (Sikh Temples) were held. The Court of Appeal had held that the issues underlying the dispute were to be found in matters of the faith of the Sikh parties, and had ordered a permanent stay. . .
CitedLetts, Regina (on The Application of) v The Lord Chancellor and Another Admn 20-Feb-2015
Application for judicial review concerning the criteria applied by the Legal Aid Agency to determine whether relatives of a deceased should be granted legal aid for representation at an inquest into a death which has arisen in circumstances which . .
CitedTyrrell v HM Senior Coroner County Durham and Darlington and Another Admn 26-Jul-2016
The court was aked what article 2 of the European Convention on Human Rights requires of a coroner when a serving prisoner dies of natural causes.
Held: The reuest for judicial review failed. Mr Tyrrell’s death was, from the outset, one which . .

Lists of cited by and citing cases may be incomplete.

Armed Forces, Coroners, Human Rights

Leading Case

Updated: 01 November 2021; Ref: scu.266539

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

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

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

Human Rights, Coroners, Armed Forces, News

Updated: 01 November 2021; Ref: scu.536666

Hurst, Regina (on the Application of) v Commissioner of Police of the Metropolis v London Northern District Coroner: HL 28 Mar 2007

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

Lord Bingham of Cornhill, Lord Rodger of Earlsferry, Baroness Hale of Richmond, Lord Brown of Eaton-under-Heywood, Lord Mance
[2007] UKHL 13, [2007] 2 WLR 726, [2007] 2 All ER 1025, [2007] 2 AC 189
Bailii
Coroners Act 1988 16(3), Human Rights Act 1998
England and Wales
Citing:
CitedRegina v North Humberside and Scunthorpe Coroner ex parte Jamieson QBD 12-Jul-1993
northhumberside_jamiesonCA1993
A prisoner had hanged himself after being left unsupervised in a single cell. He was a known suicide risk, but the Coroner directed the jury not to return a verdict which included any reference to lack of care.
Held: A coroner was free not to . .
CitedMiddleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
CitedEmpress Car Company (Abertillery) Ltd v National Rivers Authority HL 22-Jan-1998
A diesel tank was in a yard which drained into a river. It was surrounded by a bund to contain spillage, but that protection was over ridden by an extension pipe from the tank to a drum outside the bund. Someone opened a tap on that pipe so that . .
CitedIn re McKerr CANI 10-Jan-2003
The appellant’s son and two others had been shot dead by police officers. There remained considerable controversy over the circumstances. The matter had been taken to the ECHR which had found the enquiry inadequate. The parties now disputed the . .
CitedCommissioner of Police for the Metropolis v Reeves (Joint Administratix of The Estate of Martin Lynch, Deceased) HL 11-Feb-1999
The deceased was a prisoner known to be at risk of committing suicide. Whilst in police custody he hanged himself in his prison cell. The Commissioner accepted that he was in breach of his duty of care to the deceased, but not that that breach was . .
CitedRegina v South London Coroner ex parte Thompson 8-Jul-1982
The court discussed the function of the coroner and his inquest.
Lord Lane CJ said: ‘The coroner’s task in a case such as this is a formidable one, and no one would dispute that; that is quite apart from the difficulties which inevitably arise . .
CitedRegina v Southwark Coroner, ex parte Hicks QBD 1987
The verdict of ‘lack of care’ at an inquest is to be used to indicate only the condition of the deceased at the time of death as a cause of death, and is not to be used as a way of attributing fault. The admission of documentary evidence by a . .
CitedWilson v Secretary of State for Trade and Industry; Wilson v First County Trust Ltd (No 2) HL 10-Jul-2003
The respondent appealed against a finding that the provision which made a loan agreement completely invalid for lack of compliance with the 1974 Act was itself invalid under the Human Rights Act since it deprived the respondent of its property . .
Appeal fromHurst v Coroner Northern District of London Admn 4-Jul-2003
The deceased was killed by Mr Reid, a neighbour, who was convicted of his manslaughter.
Held: The court quashed the coroner’s refusal to accede to the application of the deceased’s father to resume an adjourned inquest into the death, at which . .
CitedRegina v Inner West London Coroner Ex Parte Dallaglio, and Ex Parte Lockwood Croft CA 16-Jun-1994
A coroner’s comment that the deceased’s relative was ‘unhinged’ displayed a bias which was irreparable. ‘The description ‘apparent bias’ traditionally given to this head of bias is not entirely apt, for if despite the appearance of bias the court is . .
CitedOsman v The United Kingdom ECHR 28-Oct-1998
Police’s Complete Immunity was Too Wide
(Grand Chamber) A male teacher developed an obsession with a male pupil. He changed his name by deed poll to the pupil’s surname. He was required to teach at another school. The pupil’s family’s property was subjected to numerous acts of vandalism, . .
CitedRegina v Walthamstow Coroner, Ex parte Rubenstein 19-Feb-1982
The 1988 Act was a consolidating Act. . .
CitedRegina v Secretary of State for Transport, Ex parte Factortame Ltd HL 18-May-1989
The applicants were companies owned largely by Spanish nationals operating fishing vessels within UK waters. The 1988 Act required them to re-register the vessels as British fishing vessels. The sought suspension of enforcement pending a reference . .
CitedMarleasing SA v La Comercial Internacional de Alimentacion SA ECJ 13-Nov-1990
Sympathetic construction of national legislation
LMA OVIEDO sought a declaration that the contracts setting up Commercial International were void (a nullity) since they had been drawn up in order to defraud creditors. Commercial International relied on an EC . .
CitedPearson v HM Coroner for Inner London North Admn 9-Mar-2005
Relatives of the deceased said that the inquest carried out by the coroner was inadequate in Jamieson terms and had not satisfied the human rights issues. Maurice Kay LJ rejected the argument saying: ‘One does not reach the stage of resort to . .
CitedGhaidan v Godin-Mendoza HL 21-Jun-2004
Same Sex Partner Entitled to tenancy Succession
The protected tenant had died. His same-sex partner sought a statutory inheritance of the tenancy.
Held: His appeal succeeded. The Fitzpatrick case referred to the position before the 1998 Act: ‘Discriminatory law undermines the rule of law . .
CitedImperial Chemical Industries v Colmer ECJ 16-Jul-1998
A member state was not allowed to impose a tax regime which discriminated against the subsidiaries of a company based in that state where they were based in other member states, but discrimination was allowed where the subsidiaries were based . .
CitedImperial Chemical Industries v Colmer ECJ 16-Jul-1998
A member state was not allowed to impose a tax regime which discriminated against the subsidiaries of a company based in that state where they were based in other member states, but discrimination was allowed where the subsidiaries were based . .
CitedRegina v Lyons, Parnes, Ronson, Saunders HL 15-Nov-2002
The defendants had been convicted on evidence obtained from them by inspectors with statutory powers to require answers on pain of conviction. Subsequently the law changed to find such activity an infringement of a defendant’s human rights.
CitedGingi v The Secretary of State for Work and Pensions CA 14-Nov-2001
It is possible that in some circumstances the same enactment may be construed differently according to whether it applies in circumstances covered by a directive. Arden LJ approved the following passage from Bennion: ‘It is legitimate for the . .
CitedRegina v Secretary of State for the Home Department ex parte Brind HL 7-Feb-1991
The Home Secretary had issued directives to the BBC and IBA prohibiting the broadcasting of speech by representatives of proscribed terrorist organisations. The applicant journalists challenged the legality of the directives on the ground that they . .
CitedRegina v Chief Immigration Officer, Heathrow Airport, Ex parte Salamat Bibi CA 1976
Lord Denning MR said that: ‘Treaties and declarations do not become part of our law until they are made law by Parliament’.
Iin relation to the application of broad Convention principles in the context of immigration powers, he said: ‘I . .
CitedFernandes v Secretary of State CA 1981
Article 8 of the Convention was relied upon by the appellant to resists his return.
Held: The Secretary of State in exercising his statutory powers was not obliged to take into account the provisions of the Convention, it not being part of the . .
CitedCREEDNZ Inc v The Governor General 1981
(New Zealand) The court looked at those considerations which a decision maker can choose for himself whether or not to take them into account. Cooke J said: ‘what has to be emphasised is that it is only when the statute expressly or impliedly . .
CitedIn Re Findlay, in re Hogben HL 1985
A public authority, and the Prison Service in particular, is free, within the limits of rationality, to decide on any policy as to how to exercise its discretions; it is entitled to change its policy from time to time for the future, and a person . .
CitedChundawadra v Immigration Appeal Tribunal CA 1988
Ratification of the European Convention on Human Rights did not create a justiciable legitimate expectation that the Convention’s provisions would be complied with. Slade LJ said there was no evidence of ‘any relevant express promise or regular . .
CitedRegina v Secretary of State for the Environment, Ex parte NALGO CA 1992
Neill LJ explained article 8 of the Convention in the light of Brind: ‘(1) Article 10 is not part of English domestic law. It is therefore not necessary for the Minister when exercising an administrative decision conferred on him by Parliament to . .
CitedRantzen v Mirror Group Newspapers (1986) Ltd and Others CA 1-Apr-1993
Four articles in the People all covered the same story about Esther Rantzen’s organisation, Childline, suggesting that the plaintiff had protected a teacher who had revealed to Childline abuses of children occurring at a school where he taught, by . .
CitedBolton Metropolitan Borough Council and Others v Secretary of State for Environment and Others CA 4-Aug-1994
A decision maker can take a preliminary view of a matter provided that he continues to keep an open mind. . .
CitedBolton Metropolitan District Council and Others v Secretary of State for the Environment and Others HL 25-May-1995
There had been an application in 1986 for planning permission for a shopping centre in Trafford. There were two public enquiries, followed, as public policy changed by further representations. The plaintiff complained that the eventual decision . .
CitedMcCann and Others v The United Kingdom ECHR 6-Oct-1995
mccann_ukECHR1995
Wrong assumptions made by police officers in the killing of terrorists amounted to a human rights breach, despite the existence of danger to the public of an imminent attack. Article 2(1) is ‘one of the most fundamental provisions in the . .
CitedRegina v Kansal (2) HL 29-Nov-2001
The prosecutor had lead and relied at trial on evidence obtained by compulsory questioning under the 1986 Act.
Held: In doing so the prosecutor was acting to give effect to section 433.
The decision in Lambert to disallow retrospective . .
CitedTakoushis, Regina (on the Application of) v HM Coroner for Inner North London Admn 16-Dec-2004
A patient suffering schizophrenia had been a voluntary patient. He was allowed to visit another unit within the hospital grounds, but then left altogether and was next found preparing to jump from Tower Bridge. He was taken by ambulance to Hospital . .
CitedRegina (Smeaton) v Secretary of State for Health and Others Admn 18-Apr-2002
The claimant challenged the Order as regards the prescription of the morning-after pill, asserting that the pill would cause miscarriages, and that therefore the use would be an offence under the 1861 Act.
Held: ‘SPUC’s case is that any . .
CitedA and Others, Regina (on the Application of) v Lord Saville of Newdigate and others CA 28-Jul-1999
Former soldiers who had been involved in the events in Londonderry in 1972, and were to be called to give evidence before a tribunal of inquiry, still had cause to fear from their names being given, and so were entitled to anonymity when giving such . .

Cited by:
CitedSmith, Regina (on The Application of) v Secretary of State for Defence and Oxfordshire Assistant Deputy Coroner (Equality and Human Rights Commission intervening) SC 30-Jun-2010
The deceased soldier died of heat exhaustion whilst on active service in Iraq. It was said that he was owed a duty under human rights laws, and that any coroner’s inquest should be a fuller one to satisfy the state’s duty under Article 2.
CitedMcCaughey and Another, Re Application forJudicial Review SC 18-May-2011
The claimants sought a fuller inquest into deaths at the hands of the British Army in 1990 in Northern Ireland. On opening the inquest, the coroner had declined to undertake to hold a hearing compliant with article 2, and it had not made progress. . .
CitedParkwood Leisure Ltd v Alemo-Herron and Others SC 15-Jun-2011
The claimants had been employed by a local authority and then transferred to the respondents. They had had the benefit that their terms of employment were subject to collective agreement. The respondent was not part of the negotiation of later . .
CitedANS and Another v ML SC 11-Jul-2012
The mother opposed adoption proceedings, and argued that the provision in the 2007 Act, allowing a court to dispense with her consent, infringed her rights under Article 8 and was therefore made outwith the powers of the Scottish Parliament.
CitedNHS Manchester v Fecitt and Others CA 25-Oct-2011
The appellant challenged reversal by the EAT of a finding that it had not unlawfully victimised the respondents for the making of a protected disclosure. The claimant had reported a co-worker exaggerating his qualifications. After repeated . .

Lists of cited by and citing cases may be incomplete.

Police, Coroners, Human Rights

Leading Case

Updated: 01 November 2021; Ref: scu.251022

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

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

Owen J, Toulson LJ
[2010] EWHC 931 (Admin), [2010] Inquest LR 80
Bailii
Coroners Act 1988 13
England and Wales
Citing:
CitedBloom v HM Assistant Deputy Coroner for the Northern District of London and Another Admn 20-Dec-2004
The deceased had gone to hospital and was diagnosed as having a kidney stone. As it was removed there was evidence of infection. She declined and was transferred to the local NHS hospital in intensive care. She died and a post-mortem identified . .
CitedRegina v HM Coroner, Lincoln, ex parte Hay 19-Feb-1987
. .
CitedRegina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
CitedRegina v Inner West London Coroner Ex Parte Dallaglio, and Ex Parte Lockwood Croft CA 16-Jun-1994
A coroner’s comment that the deceased’s relative was ‘unhinged’ displayed a bias which was irreparable. ‘The description ‘apparent bias’ traditionally given to this head of bias is not entirely apt, for if despite the appearance of bias the court is . .
CitedMiddleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
CitedHM Coroner for the Eastern District of London, Regina (On the Application of) v Sutovic Admn 31-Jul-2009
The deceased had died in Serbia, but was buried in Acton. A second inquest had been ordered on the request of the respondent, and an exhumation licence granted for the purposes of a second post mortem examination. The respondent had refused her . .

Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 01 November 2021; Ref: scu.408663

Lewis, Regina (on The Application of) v HM Coroner for The Mid and North Division of The County of Shropshire and Another: CA 21 Dec 2009

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

Lord Justice Sedley, Lord Justice Rimer and Lord Justice Etherton
[2009] EWCA Civ 1403, Times 11-Jan-2010
Bailii
Coroners Rules 1984 (SI 1984 No 552) 43
England and Wales
Citing:
Appeal FromLewis, Regina (On the Application of) v HM Coroner for the Mid and North Division Of the County Of Shropshire and Another Admn 3-Apr-2009
. .
CitedOneryildiz v Turkey ECHR 30-Nov-2004
(Grand Chamber) The applicant had lived with his family in a slum bordering on a municipal household refuse tip. A methane explosion at the tip resulted in a landslide which engulfed the applicant’s house killing his close relatives.
Held: The . .
CitedSacker, Regina (on the Application of) v Coroner for the County of West Yorkshire HL 11-Mar-2004
The deceased committed suicide in prison. Her family sought to have added to the verdict the words ‘contributed by neglect’ and complained that the inquest had not provided a full and proper investigation of the death.
Held: The Act needed to . .
CitedAllen, Regina (On the Application of) v Coroner for Inner North London CA 25-Jun-2009
. .
CitedMiddleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
Coroners, Human Rights

Leading Case

Updated: 01 November 2021; Ref: scu.392510

Regina v HM Coroner ex parte Chief Constable of South Wales: Admn 1999

The deceased was found in the street having taken drink and drugs. At a police station he was seen by a doctor who found him fit to be detained, but he died next morning. A jury recorded a verdict of ‘drug abuse contributed to by neglect’. It was contended on behalf of the Chief Constable that there was no evidence of neglect to be left to the jury.
Held: The court rejected that submission, but concluded that the interest of justice did require second inquest: ‘(1) the coroners explanation of what constituted ‘neglect’ was erroneous. He began with a correct definition. Unfortunately he then amplified that definition in terms which suggested that simple negligence would suffice . . . (2) The coroner failed to give any direction in relation to causation . . . the jury must be satisfied that there was a clear and direct causal connection between the gross failure or failures by the police and the cause of death.’
Jackson J
[1999] 164 JP 191
England and Wales
Cited by:
CitedRegina on the Application of Mullholland v HM Coroner for St Pancras QBD 7-Nov-2003
The applicant sought to re-open a coroner’s inquest. The deceased had been drunk, slipped banged his head and fallen to the ground. Police and ambulance were called. The ambulance worker was not told he had been unconscious, and he was taken to the . .

Lists of cited by and citing cases may be incomplete.
Updated: 27 September 2021; Ref: scu.187757

Regina v Coroner for Western District of Sussex Ex Parte Homberg Roberts and Mannerss: QBD 27 Jan 1994

A Coroner’s enquires should be as to ‘how’ the death arose, and not into all the circumstances contributing to the death.
Simon Brown LJ said: ‘It is clear that the coroner’s over-riding duty is to inquire ‘how’ the deceased came by his death and that duty prevails over any inhibition against appearing to determine questions of criminal or civil liability . . Secondly, the cases establish that although the is word ‘how’ is to be widely interpreted, it means ‘by what means’ rather than ‘in what broad circumstances’ . . In short the inquiry must focus on matters directly causative of death and must indeed, be confined to these matters alone (save for ascertainment of the other specific details mentioned in r36(1)). The recent, 11th edition of Jervis on Coroners puts it like this: ‘The question of how the deceased came by his death is of course wider than merely finding the principal cause of death, and it is therefore right and proper that the coroner should inquire into acts and omissions which are directly responsible for the death.’ and ‘The duty to inquire ‘how’ the deceased dies does not to my mind properly encompass inquiry also into the underlying responsibility for every circumstance which may be said to have contributed to the death.’
‘It is the duty of the coroner as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the facts are fully, fairly and fearlessly investigated. He is bound to recognise the acute public concern rightly aroused when deaths occur in custody. He must ensure that the relevant facts are exposed to public scrutiny, particularly if there is evidence of foul play, abuse or inhumanity. He fails in his duty if his investigation is superficial, slipshod or perfunctory. But the responsibility is his. He must set the bounds of the inquiry.’
Morland J ‘In my judgment the purpose of such a jury inquest under s8(3)(d) is clear. It is so that lessons can be learned from the circumstanmces of the death so that in future the risk of injuries to health and safety arising from similar circiumstances should be prevented or reduced.’
Simon Brown LJ, Morland J
Independent 27-Jan-1994, (1994) 158 JP 357
Coroners Rules 1984 36(1)
England and Wales
Cited by:
CitedMiddleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
CitedMiddleton, Regina (on the Application of) v Coroner for the Western District of Somerset Admn 14-Dec-2001
The deceased had committed suicide whilst in prison. It was argued that the prison should have recognised that he was a suicide risk, and acted accordingly. The coroner had requested a note from the jury as to the cause of death. The court . .
CitedIn Re Neal (Coroner: Jury) QBD 17-Nov-1995
The father of the deceased sought to have the coroner quash the inquest. His daughter had died in Spain from carbon monoxide poisoning, apparently emanated from a faulty water heater in the apartment in which she had stayed. Her body had been . .
CitedTakoushis, Regina (on the Application of) v HM Coroner for Inner North London and others CA 30-Nov-2005
Relatives sought judicial review of the coroner’s decision not to allow a jury, and against allowance of an expert witness. The deceased had been a mental patient but had been arrested with a view to being hospitalised. He was taken first to the . .
CitedRegina v Inner West London Coroner Ex Parte Dallaglio, and Ex Parte Lockwood Croft CA 16-Jun-1994
A coroner’s comment that the deceased’s relative was ‘unhinged’ displayed a bias which was irreparable. ‘The description ‘apparent bias’ traditionally given to this head of bias is not entirely apt, for if despite the appearance of bias the court is . .

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

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

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

Updated: 14 July 2021; Ref: scu.565722

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

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

Updated: 09 July 2021; Ref: scu.471739

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

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

Updated: 02 June 2021; Ref: scu.86140

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

In 1948, there had been an incident in what later became part of Malaysia, in a counter insurgency patrol, when 24 civilians were said to have been killed by a patrol from the Scots Guards. The claimant now appealed against the refusal of a further inquiry.
Held: The appeal failed.
Maurice Kay, Rimer, Fulford LJJ
[2014] 4 All ER 99, [2014] WLR(D) 138, [2015] 1 QB 57, [2014] 3 WLR 948
Bailii, WLRD
European Convention on Human Rights 2, Inquiries Act 2005 1, Human Rights Act 1998
England and Wales
Citing:
CitedIn re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
Appeal fromKeyu and Others v Secretary of State for Foreign and Commonwealth Affairs and Another Admn 4-Sep-2012
It was said that a squad of the British army had caused the deaths of 24 civilians in 1948 in Batang Kali (now part of Malaysia.
Held: No inquiry was required. It was a matter of discretion, and there were no sustainable reasons for . .

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

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

Revenue and Customs, Regina (on The Application of) v HM Coroner for The City of Liverpool: Admn 21 May 2014

The Coroner, conducting an investigation into a person’s death, issued notices under para 1(2) of Schedule 5 to the Coroners and Justice Act 2009, requiring the Revenue and Customs Commissioners to provide occupational information concerning the deceased for the purpose of investigating whether he had died as a result of an industrial disease. The Commissioner sought judicial review of the decision to issue those notices and asserted that the 2009 Act, which did not expressly bind the Crown, did not do so by necessary implication either. The Revenue said that compliance with the notice would pt them in breach of their own duties of confidentiality under the 2005 Act.
Held: Schedule 5 to the CJA 2009 binds the Crown by necessary implication. It follows that the Notices constituted an ‘order of court’ within s.18(2)(e), CRCA 2005, binding on HMRC. It follows further that the duty of confidentiality flowing from s.18(1), CRCA 2005 was displaced and HMRC was entitled to comply with the Notices.
Gross LJ, Burnett J
[2014] EWHC 1586 (Admin), [2015] 1 QB 481, [2014] 3 WLR 1660, [2014] WLR(D) 226
Bailii, WLRD
Coroners and Justice Act 2009, Commissioners for Revenue and Customs Act 2005, European Convention of Human Rights 2
England and Wales
Citing:
Dictum adoptedThe British Broadcasting Corporation v Johns (HM Inspector of Taxes) CA 5-Mar-1964
The BBC claimed to be exempt from income tax. It claimed crown immunity as an emanation of the crown. The court had to decide whether the BBC was subject to judicial review.
Held: It is not a statutory creature; it does not exercise statutory . .

Cited by:
CitedBlack, Regina (on The Application of) v Secretary of State for Justice Admn 5-Mar-2015
The serving prisoner said that new general restrictions on smoking in public buildings applied also in prisons. were a breach of his human rights. The only spaces where prisoners were allowed now to smoke were their cells, and he would share cells . .
CitedSecretary of State for Justice v Black CA 8-Mar-2016
The Secretary of State appealed against a declaration that the provisions prohibiting smoking in pubic places applied in prisons.
Held: The appeal succeeded. . .
CitedBlack, Regina (on The Application of) v Secretary of State for Justice SC 19-Dec-2017
The Court was asked whether the Crown is bound by the prohibition of smoking in most enclosed public places and workplaces, contained in Chapter 1 of Part 1 of the Health Act 2006.
Held: However reluctantly, the claimant’s appeal was . .
CitedBlack, Regina (on The Application of) v Secretary of State for Justice Admn 5-Mar-2015
The serving prisoner said that new general restrictions on smoking in public buildings applied also in prisons. were a breach of his human rights. The only spaces where prisoners were allowed now to smoke were their cells, and he would share cells . .

These lists may be incomplete.
Updated: 12 May 2021; Ref: scu.526075

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 overturning the decisions of the respondents.
Sir John Thomas P, Treacy J
[2012] EWHC 2445 (Admin), [2012] WLR(D) 261
Bailii, WLRD
Inquiries Act 2005 1, Human Rights Act 1998, European Convention on Human Rights
England and Wales
Citing:
CitedIn re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .

Cited by:
Appeal fromKeyu and Others v Secretary of State for Foreign and Commonwealth Affairs and Another CA 19-Mar-2014
In 1948, there had been an incident in what later became part of Malaysia, in a counter insurgency patrol, when 24 civilians were said to have been killed by a patrol from the Scots Guards. The claimant now appealed against the refusal of a further . .
At first instanceKeyu and Others v Secretary of State for Foreign and Commonwealth Affairs and Another SC 25-Nov-2015
The Court was asked whether the respondents should be required to hold a public inquiry into a controversial series of events in 1948, when a Scots Guards patrol was alleged to shot and killed 24 unarmed civilians in a village called Batang Kali, in . .

These lists may be incomplete.
Updated: 19 April 2021; Ref: scu.463812

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 but were not disclosed to the coroner until the last day of the inquest and had not been admitted to evidence.
Held: Comments in the Gentle case were obiter. The claimant’s case succeeded. The right to life may protect soldiers serving outside Europe in situations where as here the service was in effective control of an area.
Collins J
[2008] EWHC 694 (Admin), Times 30-May-2008, [2008] 3 WLR 1284, (2008) 103 BMLR 152, [2008] ACD 45
Bailii
European Convention on Human Rights 2
England and Wales
Citing:
CitedGentle, Regina (on the Application of) and Another v The Prime Minister and Another HL 9-Apr-2008
The appellants were mothers of two servicemen who had died whilst on active service in Iraq. They appealed refusal to grant a public inquiry. There had already been coroners inquests. They said that Article 2 had been infringed.
Held: The . .
CitedBankovic v Belgium ECHR 12-Dec-2001
(Grand Chamber) Air strikes were carried out by NATO forces against radio and television facilities in Belgrade on 23 April 1999. The claims of five of the applicants arose out of the deaths of relatives in this raid. The sixth claimed on his own . .
CitedSecretary of State for Defence v Al-Skeini and others (The Redress Trust Intervening) HL 13-Jun-2007
Complaints were made as to the deaths of six Iraqi civilians which were the result of actions by a member or members of the British armed forces in Basra. One of them, Mr Baha Mousa, had died as a result of severe maltreatment in a prison occupied . .
CitedSerco Ltd v Lawson; Botham v Ministry of Defence; Crofts and others v Veta Limited HL 26-Jan-2006
Mr Lawson was employed by Serco as a security supervisor at the British RAF base on Ascension Island, which is a dependency of the British Overseas Territory of St Helena. Mr Botham was employed as a youth worker at various Ministry of Defence . .
CitedMartin v The United Kingdom ECHR 24-Oct-2006
The claimant was living with his family with the Army in Germany. Though he was a civilian, he was convicted by a court martial of murder. He complained that it was wrong that he had been subject to a military tribunal and that there had been an . .
CitedMulcahy v Ministry of Defence CA 21-Feb-1996
A soldier in the Artillery Regiment was serving in Saudi Arabia in the course of the Gulf war. He was injured when he was part of a team managing a Howitzer, which was firing live rounds into Iraq, and he was standing in front of the gun when it was . .
CitedJordan v United Kingdom; McKerr v United Kingdom; similar ECHR 4-May-2001
Proper Investigation of Deaths with Army or Police
Claims were made as regards deaths of alleged terrorists in clashes with the UK armed forces and police. In some cases the investigations necessary to justify the taking of life had been inadequate. Statements made to the inquiry as to the . .
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.
Cited by:
Appeal fromSecretary of State for Defence v Smith, Regina (on the Application of) CA 18-May-2009
The soldier had died of heatstroke after exercises in Iraq. The Minister appealed against a finding that the circumstances of his death required an investigation compliant with Article 2 human rights, saying that he was not subject to such . .
At First InstanceSmith, 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.
Updated: 10 April 2021; Ref: scu.266897

Nicholls v Coroner for City of Liverpool: Admn 8 Nov 2001

As the deceased was arrested he swallowed something. He was examined by a doctor and denied that he had swallowed drugs, but his condition deteriorated and he died at hospital. The coroner refused to admit the evidence of a professor who was highly critical of the conduct of the doctor who had seen the deceased, and said that an antidote should have been prescribed. The coroner found insufficient evidence of neglect to leave that issue to the jury, and they returned a verdict of death by misadventure.
Held: The professor should have been called even though it might well have led to a further adjournment ‘measured in weeks or perhaps one to two months’. The coroner’s principal reason for refusing to call the professor was that his report was concerned on its face not with neglect applying the Jamieson test, but with medical negligence applying the Bolam test, ‘Notwithstanding Mr Burnett’s submission that neglect and negligence are two different ‘animals’, there is, in reality, no precise dividing line between ‘a gross failure to provide . . basic medical attention’ and a ‘failure to provide… medical attention’. The difference is bound to be one of degree, highly dependent on the facts of the particular case. . . . Standing back and looking at the facts of the present case, one starts with a death in custody. As the then Master of the Rolls said in Jamieson, such deaths rightly arouse acute public concern. Professor Redmond’s report stated that this death in custody was ‘entirely preventable’ by steps that could have been expected of any doctor acting to a reasonable standard. . . . Such a statement in respect of the death of a person in custody pointed to a need for the fullest investigation. The steps that Professor Redmond was suggesting would have been taken by any doctor acting to a reasonable standard were neither complex nor sophisticated. They amounted to doing no more than checking the patient’s respiratory rate and the arranging for it to be checked after about another hour, rather than simply leaving the patient until the next morning . . . So far as causation is concerned … in my judgment it is important not to read the Master of the Rolls words in Jamieson as though they were contained in an enactment, or to apply them in an over literal manner.’
Application for judicial review of coroner’s decision on behalf of child daughter of deceased. He had died in police custody having taken opiates. The coroner had refused an adjournment for the family to call expert evidence as to the proper treatment of such a patient.
Held: The coroner’s reasons for not allowing the adjournment for the evidence did not stand up. As a death in police custody, it required a full public examination. That had not been done, and the verdict of misadventure was quashed and a fresh inquest was ordered.
Rose LJ, Sullivan J
[2001] EWHC Admin 922, [2001] EWHC 922 (Admin), [2001] Inquest LR 249, [2002] ACD 13
Bailii
Coroners Act 1988 13
England and Wales
Citing:
CitedLadd v Marshall CA 29-Nov-1954
Conditions for new evidence on appeal
At the trial, the wife of the appellant’s opponent said she had forgotten certain events. After the trial she began divorce proceedings, and informed the appellant that she now remembered. He sought either to appeal admitting fresh evidence, or for . .

Cited by:
CitedKhan, Regina (on the Application of) v HM Coroner for West Hertfordshire and Another Admn 7-Mar-2002
The deceased died in police custody. The coroner refused to leave to the jury possible verdicts of unlawful killing, or death contributed to by neglect, or breach of his right to life. He adjourned the hearing to allow this challenge.
Held: . .
CitedRegina on the Application of Mullholland v HM Coroner for St Pancras QBD 7-Nov-2003
The applicant sought to re-open a coroner’s inquest. The deceased had been drunk, slipped banged his head and fallen to the ground. Police and ambulance were called. The ambulance worker was not told he had been unconscious, and he was taken to the . .

These lists may be incomplete.
Updated: 07 March 2021; Ref: scu.432775

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 had been refused an undertaking by the coroner that the inquest would be compliant with the requirements of Article 2.
Held: Review was refused. McKerr was binding, even if inconsistent with Silih. If Silih was to be extended to apply in the UK, it would be for a higher court to overrule McKerr.
Weatherup J
[2009] NIQB 77
Bailii
Coroner’s (Practice and Procedure) Rules (Northern Ireland) 1963, European Convention on Human Rights 2
Northern Ireland
Citing:
CitedIn re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
CitedSilih v Slovenia ECHR 9-Apr-2009
(Grand Chamber) Article 2 imposes, in certain circumstances, a freestanding obligation in relation to the investigation of a death which applied even where the death itself had occurred before the member state ratified the Convention.: ”The court . .

Cited by:
Appeal fromMcCaughey and Quinn, Re Judicial Review CANI 26-Mar-2010
The claimants challenged the mode of inquest sought to be carried out. They had been refused an undertaking that the inquest would comply with obligations under article 2.
Held: The appeal failed. McKerr remained binding on the court, even if . .
At first instanceMcCaughey 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. . .

These lists may be incomplete.
Updated: 19 February 2021; Ref: scu.377873

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 but, left to wait, he again left, and a person of his description was seen shortly afterwards to jump into the river at St Katherine’s Dock and some weeks later his body was recovered from the river at Wapping. Mrs Takoushis applied for judicial review of the inquest. She said that the enquiry had been insufficient to satisfy the requirements of article 2 of the ECHR because the Coroner had refused to allow her to call expert evidence relating to the quality of care that her husband had received at the hospital prior to his death. The hospital took part in the proceedings as an interested party.
Held: The judge noted that the hospital had accepted that article 2 was engaged. In view of that it was not necessary for him to pursue that point.
Sir Anthony Clarke MR said: ‘Although the possible verdicts at an inquest under the 1988 Act are circumscribed and, in particular must not ascribe criminal or civil liability, that does not mean that the facts should not be fully investigated . .’
Elias J
[2004] EWHC 2922 (Admin)
Bailii
Coroners Act 1988, European Convention on Human Rights 2
England and Wales
Citing:
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.
Cited by:
Appeal fromTakoushis, 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 . .
CitedGoodson v HM Coroner for Bedfordshire and Luton and Another (No 2) CA 12-Oct-2005
The applicant intended to appeal refusal of her challenge to the verdict of the coroner. For the first time at appeal she sought a protective costs order.
Held: The Corner House case established that a request for a protective costs order . .
CitedGentle, Regina (on the Application of) and Another v The Prime Minister and Another HL 9-Apr-2008
The appellants were mothers of two servicemen who had died whilst on active service in Iraq. They appealed refusal to grant a public inquiry. There had already been coroners inquests. They said that Article 2 had been infringed.
Held: The . .
CitedHurst, Regina (on the Application of) v Commissioner of Police of the Metropolis v London Northern District Coroner HL 28-Mar-2007
The claimant’s son had been stabbed to death. She challenged the refusal of the coroner to continue with the inquest with a view to examining the responsibility of any of the police in having failed to protect him.
Held: The question amounted . .
CitedSavage v South Essex Partnership NHS Foundation Trust (MIND intervening) HL 10-Dec-2008
The deceased had committed suicide on escaping from a mental hospital. The Trust appealed against a refusal to strike out the claim that that they had been negligent in having inadequate security.
Held: The Trust’s appeal failed. The fact that . .

These lists may be incomplete.
Updated: 16 February 2021; Ref: scu.221032

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

[2009] EWHC 661 (Admin)
Bailii
England and Wales
Cited by:
Appeal FromLewis, Regina (on The Application of) v HM Coroner for The Mid and North Division of The County of Shropshire and Another CA 21-Dec-2009
The claimant’s son was found hanging in his prison cell. He appealed refusal of a judicial review of the coroner’s decision not to put to the jury a question as to certain possible causative matters. The youth was seen hanging, but the guard called . .

These lists may be incomplete.
Updated: 14 February 2021; Ref: scu.341532

Borrows v HM Coroner for Preston: QBD 15 May 2008

The family members disputed who should have custody of the deceased’s body and the right to make arrangements for the funeral.
Cranston J
[2008] EWHC 1387 (QB), [2008] EWHC 1387 (Admin), [2008] Fam Law 984, [2008] 2 FLR 1225
Bailii
Cremation Regulations 1930 8
England and Wales
Cited by:
CitedRe JS (Disposal of Body) FD 10-Nov-2016
Child’s Wish for post-mortem cryonic Preservation
JS, a child of 14, anticipating her death from cancer expressed the desire that her body should receive cryonic preservation in the hope that one day a treatment might be available to allow her to be revived, and proceedings were issued. Her parents . .

These lists may be incomplete.
Updated: 08 February 2021; Ref: scu.270485

Tarariyeva v Russia: ECHR 14 Dec 2006

A complaint was made that the authorities had failed in their duty to protect a prisoner’s life. The authorities had him in custody for two years and knew of his health problems. He was not properly treated in the penal colony. When he had acute pain, he was diagnosed with a perforated ulcer and peritonitis and transferred to a civilian hospital. The surgery performed there was defective. The civilian hospital authorised his discharge to the prison hospital knowing of post-operative complications requiring further surgery, but withheld crucial details from the prison, which treated him as an ordinary post-operative patient rather than an emergency case. The further surgery was performed too late and the patient died.
Held: The complaint succeeded. The Court examined the individual operational failings of the health care given to prisoners, and not simply whether there were proper systems in place.
The court discussed the general principles applicable to the protection of the right to life: ‘The Court reiterates that . . art.2 . . requires the state not only to refrain from the ‘intentional’ taking of life, but also to take appropriate steps to safeguard the lives of those within its jurisdiction. In the context of prisoners, the Court has already emphasised in previous cases that persons in custody are in a vulnerable position and that the authorities are under a duty to protect them. It is incumbent on the state to account for any injuries suffered in custody, which obligation is particularly stringent where the individual dies.
Those obligations apply in the public-health sphere too. The positive obligations require states to make regulations compelling hospitals, whether private or public, to adopt appropriate measures for the protection of patients’ lives. They also require an effective independent judicial system to be set up so that the cause of death of patients in the care of the medical profession, whether in the public or the private sector, and those responsible made accountable. Furthermore, where a hospital is a public institution, the acts and omissions of its medical staff are capable of engaging the responsibility of the respondent State under the Convention.’
4353/03, [2006] ECHR 1096, [2007] Prison LR 270, [2008] Inquest LR 209, (2009) 48 EHRR 26
Bailii
European Convention on Human Rights
Cited by:
CitedSavage v South Essex Partnership NHS Foundation Trust (MIND intervening) HL 10-Dec-2008
The deceased had committed suicide on escaping from a mental hospital. The Trust appealed against a refusal to strike out the claim that that they had been negligent in having inadequate security.
Held: The Trust’s appeal failed. The fact that . .
CitedTyrrell v HM Senior Coroner County Durham and Darlington and Another Admn 26-Jul-2016
The court was aked what article 2 of the European Convention on Human Rights requires of a coroner when a serving prisoner dies of natural causes.
Held: The reuest for judicial review failed. Mr Tyrrell’s death was, from the outset, one which . .

These lists may be incomplete.
Updated: 01 February 2021; Ref: scu.248183

McCaughey, Re Application for Judicial Review: CANI 6 Apr 2006

[2006] NICA 13
Bailii
Northern Ireland
Cited by:
CitedJordan v Lord Chancellor and Another (Northern Ireland) HL 28-Mar-2007
In each case a death had occurred many years earlier where the deceased had apparently died at the hands of the armed forces. The relatives now challenged the range of verdicts which could be left to a coroner’s jury.
Lord Bingham said: ‘The . .

These lists may be incomplete.
Updated: 28 January 2021; Ref: scu.240124

Plymouth City Council v HM Coroner for the County of Devon and Another: Admn 27 May 2005

The local authority in whose care the deceased child had been held challenged a decision by the coroner not to limit his inquiry to the last few days of the child’s life. The coroner had decided that he had an obligation to conduct a wider enquiry under the 1968 Act.
Held: ‘The central question in the case is narrow, namely whether the child protection agencies, in particular Plymouth, arguably knew or ought to have known of a real and immediate risk to Perrin’s life. ‘ It was not whether a care order should have been sought. The coroner had looked to the wrong question, and the decision was quashed.
Wilson J
[2005] EWHC 1014 (Admin), [2005] 2 FCR 428
Bailii
Human Rights Act 1998
England and Wales
Citing:
CitedCalvelli And Ciglio v Italy ECHR 17-Jan-2002
The applicants’ baby had died shortly after birth in 1987. They complained about the medical care. The complaint was not investigated speedily by the authority, resulting in a criminal complaint becoming time barred after a conviction in 1994 was . .
CitedEdwards v The United Kingdom ECHR 14-Mar-2002
The deceased, a young man of mixed race, had been placed in a cell with another prisoner who was known to be violent, racist, and mentally unstable. The staff knew that the panic button was defective. The deceased was murdered by his cell-mate. His . .
CitedAmin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
The deceased had been a young Asian prisoner. He was placed in a cell overnight with a prisoner known to be racist, extremely violent and mentally unstable. He was killed. The family sought an inquiry into the death.
Held: There had been a . .
CitedMiddleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
CitedKhan, Regina (on the Application of) v Secretary of State for Health CA 10-Oct-2003
The claimant’s child had died as a result of negligence in hospital. The parents had been told the result of police investigation and decision not to prosecute, and the hospital’s own investigation, but had not been sufficiently involved. There . .
CitedHurst v Coroner Northern District of London Admn 4-Jul-2003
The deceased was killed by Mr Reid, a neighbour, who was convicted of his manslaughter.
Held: The court quashed the coroner’s refusal to accede to the application of the deceased’s father to resume an adjourned inquest into the death, at which . .
CitedE and Others v The United Kingdom ECHR 26-Nov-2002
The four applicants had been abused by their stepfather, and sought investigation of the local authority for failing to protect them. They had been compensated by the Criminal Injuries Compensation Authority in part, but now sought a remedy from the . .
CitedIn Re J (Minors) (Care: Care Plan) FD 1994
The judge had found that the threshold criteria in section 31 had been met, but the authority changed the care plan immediately before the final hearing. The guardian now appealed a final order, having proposed an interim order.
Held: Once the . .
CitedOsman v The United Kingdom ECHR 28-Oct-1998
Police’s Complete Immunity was Too Wide
(Grand Chamber) A male teacher developed an obsession with a male pupil. He changed his name by deed poll to the pupil’s surname. He was required to teach at another school. The pupil’s family’s property was subjected to numerous acts of vandalism, . .
CitedMastromatteo v Italy ECHR 24-Oct-2002
The deceased had been a bystander killed by a group of criminals, some of whom were on leave of absence from prison and one of whom had absconded from prison. A complaint was made by the applicant that there had been a breach of the positive duty to . .
CitedRegina (A and others) (Widgery Soldiers) v Lord Saville of Newdigate and Others CA 19-Dec-2001
The court would apply common sense in deciding whether soldier witnesses should be obliged to attend in person at an enquiry in Londonderry, where they claimed their lives would be at risk. It was not appropriate to seek to define what would be . .
CitedRe M (Threshold Criteria: Parental Concessions) CA 1999
In care proceedings the court is not constrained to take the shortest route to an uncontested disposal. Though, the court identified as a general principle ‘there should be no unnecessary litigation in the courts’. . .
CitedZ And Others v The United Kingdom ECHR 10-May-2001
Four children complained that, for years before they were taken into care by the local authority, its social services department was well aware that they were living in filthy conditions and suffering ‘appalling’ neglect in the home of their . .
CitedRe C and B (Care Order: Future Harm) CA 2001
Hale LJ said that ‘a comparatively small risk of really serious harm can justify action, while even the virtual certainty of slight harm might not’. . .
CitedPowell v United Kingdom ECHR 4-May-2000
A ten-year old boy had died from Addison’s disease. No inquest took place, because the coroner decided that the boy had died of natural causes. The parents, who were also affected by the events, had accepted compensation from the local health . .

Cited by:
CitedScholes, Regina (on the Application of) v Secretary of State for the Home Department Admn 16-Jan-2006
The deceased had committed suicide whilst in a Young Offenders Institute. The coroner had called for a further enquiry into the way he had been sentenced. The Home Office refused a public enquiry saying that the coroner’s inquest had satisfied its . .

These lists may be incomplete.
Updated: 23 January 2021; Ref: scu.226743

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 or failure to protect someone in custody.’
Held: ‘Calvelli is both the most recent decision and also a decision of the Grand Chamber; and the judgment in that case analyses the matter solely in terms of the positive obligation to set up an effective judicial system, without reference to the separate procedural obligation to investigate . . Whether the matter is analysed in terms of the positive obligation to set up an effective judicial system or in terms of the procedural obligation to investigate may not ultimately be of great significance. Although certain minimum criteria are laid down, the actual nature of an investigation required under article 2 varies according to context; and the Strasbourg cases on deaths resulting from alleged medical negligence show that, if the procedural obligation does apply, the range of remedies available under the judicial system (criminal, civil and possibly disciplinary) can be sufficient to discharge it.’
Richards J
[2004] EWHC 2931 (Admin), [2005] 2 All ER 791, [2006] 1 WLR 432, [2005] Lloyds Rep Med 202, (2005) 84 BMLR 72, [2005] Lloyd’s Rep Med 202
Bailii
Citing:
CitedCalvelli And Ciglio v Italy ECHR 17-Jan-2002
The applicants’ baby had died shortly after birth in 1987. They complained about the medical care. The complaint was not investigated speedily by the authority, resulting in a criminal complaint becoming time barred after a conviction in 1994 was . .

Cited by:
CitedD, Regina (on the Application of) v Secretary of State for the Home Department Admn 28-Apr-2005
D was undergoing trial for offences and was held in prison. He self-harmed repeatedly, and was recorded to require extra vigilance. He attempted to hang himself. Prison staff saved his life, but he was left paraplegic, and was then detained under . .
CitedD, Regina (on the Application of) v Secretary of State for the Home Department Admn 28-Apr-2005
D was undergoing trial for offences and was held in prison. He self-harmed repeatedly, and was recorded to require extra vigilance. He attempted to hang himself. Prison staff saved his life, but he was left paraplegic, and was then detained under . .
CitedTakoushis, Regina (on the Application of) v HM Coroner for Inner North London and others CA 30-Nov-2005
Relatives sought judicial review of the coroner’s decision not to allow a jury, and against allowance of an expert witness. The deceased had been a mental patient but had been arrested with a view to being hospitalised. He was taken first to the . .
See AlsoGoodson v HM Coroner for Bedfordshire and Luton and Another (No 2) CA 12-Oct-2005
The applicant intended to appeal refusal of her challenge to the verdict of the coroner. For the first time at appeal she sought a protective costs order.
Held: The Corner House case established that a request for a protective costs order . .
CitedSavage v South Essex Partnership NHS Foundation Trust (MIND intervening) HL 10-Dec-2008
The deceased had committed suicide on escaping from a mental hospital. The Trust appealed against a refusal to strike out the claim that that they had been negligent in having inadequate security.
Held: The Trust’s appeal failed. The fact that . .
CitedTyrrell v HM Senior Coroner County Durham and Darlington and Another Admn 26-Jul-2016
The court was aked what article 2 of the European Convention on Human Rights requires of a coroner when a serving prisoner dies of natural causes.
Held: The reuest for judicial review failed. Mr Tyrrell’s death was, from the outset, one which . .

These lists may be incomplete.
Updated: 22 January 2021; Ref: scu.221030

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 died of a cardiac arrest whilst being restrained pending the arrival of a doctor. The family believed excessive force had been used. The coroner’s jury returned a verdict of unlawful killing. The officers asked the court to quash the verdict.
Held: The coroner would have been justified in not leaving the verdict of unlawful killing to the jury: ‘The evidence to support it was very tenuous and the absence of any criticism of the police was a telling point. But it was more likely that being held face down would have produced hypoxia and so it was open to the jury to find causation proved. It was vitally important that they should have received a careful direction so that they knew that it was only if the holding face down had contributed substantially to hypoxia and that hypoxia had contributed substantially to death that a verdict of unlawful killing could be found. They received no such direction. Thus I am just persuaded that the coroner did not err in law in leaving unlawful killing to the jury. Equally, he would not have erred if he had declined to leave it. ‘ However: ‘I have no doubt that a verdict of unlawful killing was not and would not be a just verdict.’ The verdict was quashed.
Mr Justice Collins
[2004] EWHC 2729 (Admin)
Bailii
Mental Health Act 1983 136
England and Wales
Citing:
CitedPalmer v The Queen PC 23-Nov-1970
It is a defence in criminal law to a charge of assault if the defendant had an honest belief that he was going to be attacked and reacted with proportionate force: ‘If there has been an attack so that defence is reasonably necessary, it should be . .
CitedMiddleton, Regina (on the Application of) v Coroner for the Western District of Somerset HL 11-Mar-2004
The deceased had committed suicide in prison. His family felt that the risk should have been known to the prison authorities, and that they had failed to guard against that risk. The coroner had requested an explanatory note from the jury.
CitedRegina v HM Coroner for Inner London South District, ex parte Douglas-Williams CA 29-Jan-1998
r_hmcilsdwCA1998
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. . .
CitedRegina v Galbraith CCA 1981
Rejection of Submission of No Case to Answer
The defendant had faced a charge of affray. The court having rejected his submission of having no case to answer, he had made an exculpatory statement from the dock. He appealed against his conviction.
Held: Lord Lane LCJ said: ‘How then . .
CitedRegina v HM Coroner for Inner London South District, ex parte Douglas-Williams CA 29-Jan-1998
r_hmcilsdwCA1998
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. . .

These lists may be incomplete.
Updated: 21 January 2021; Ref: scu.220045

McCaughey and Another, Re Application for Judicial Review: QBNI 20 Jan 2004

Application by the fathers of Martin McCaughey and Desmond Grew, who were killed by soldiers on 9 October 1990, for Judicial Review of the decisions of the Chief Constable and the Coroner concerning the disclosure of documents for the purposes of the Inquests into the deaths.
Weatherup J
[2004] NIQB 2
Bailii
Northern Ireland
Cited by:
CitedIn re McKerr (Northern Ireland) HL 11-Mar-2004
The deceased had been shot by soldiers of the British Army whilst in a car in Northern Ireland. The car was alleged to have ‘run’ a checkpoint. The claimants said the investigation, now 20 years ago, had been inadequate. The claim was brought under . .
CitedJordan v Lord Chancellor and Another (Northern Ireland) HL 28-Mar-2007
In each case a death had occurred many years earlier where the deceased had apparently died at the hands of the armed forces. The relatives now challenged the range of verdicts which could be left to a coroner’s jury.
Lord Bingham said: ‘The . .
See AlsoPolice Service of Northern Ireland v McCaughey and Another CANI 14-Jan-2005
. .
See AlsoMcCaughey and Quinn, Re Judicial Review CANI 26-Mar-2010
The claimants challenged the mode of inquest sought to be carried out. They had been refused an undertaking that the inquest would comply with obligations under article 2.
Held: The appeal failed. McKerr remained binding on the court, even if . .
See AlsoMcCaughey 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. . .

These lists may be incomplete.
Updated: 11 January 2021; Ref: scu.192356

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 blame attached to state authorities for the killing and no breach of the state’s investigative duty was found.
Held: While certain familiar principles were rehearsed, the complaint was held to be manifestly ill-founded.
‘The Court observes that the applicants have not laid any blame on the authorities of the respondent State for the actual death of Michael Menson; nor has it been suggested that the authorities knew or ought to have known that Michael Menson was at risk of physical violence at the hands of third parties and failed to take appropriate measures to safeguard him against that risk. The applicants’ case is therefore to be distinguished from cases involving the alleged use of lethal force either by agents of the State or by private parties with their collusion (see, for example, McCann v United Kingdom (1995) [21 EHRR 97]; Jordan v United Kingdom (2001) [37 EHRR 52]; Shanaghan v United Kingdom, (Application No 37715/97, BAILII: [2001] ECHR 330), judgment of 4 May 2001, ECHR 2001-III (extracts), or in which the factual circumstances imposed an obligation on the authorities to protect an individual’s life, for example where they have assumed responsibility for his welfare (see, for example, Edwards v United Kingdom (2002) [35 EHRR 487]), or where they knew or ought to have known that his life was at risk (see, for example, Osman v United Kingdom (1998) 29 EHRR 245 . . However, the absence of any direct state responsibility for the death of Michael Menson does not exclude the applicability of article 2. It recalls that by requiring a State to take appropriate steps to safeguard the lives of those within its jurisdiction (see LCB v United Kingdom (1998) 27 EHRR 212] para 36), article 2 para 1 imposes a duty on that state to secure the right to life by putting in place effective criminal law provisions to deter the commission of offences against the person, backed up by law enforcement machinery for the prevention, suppression and punishment of breaches of such provisions.
With reference to the facts of the instant case, the Court considers that this obligation requires by implication that there should be some form of effective official investigation when there is reason to believe that an individual has sustained life-threatening injuries in suspicious circumstances. The investigation must be capable of establishing the cause of the injuries and the identification of those responsible with a view to their punishment. Where death results, as in Michael Menson’s case, the investigation assumes even greater importance, having regard to the fact that the essential purpose of such an investigation is to secure the effective implementation of the domestic laws which protect the right to life.’
47916/99, [1998] ECHR 107, (2003) 37 EHRR CD 220, [2003] Inquest LR 146, [2003] Po LR 155
Bailii
European Convention on Human Rights 2
Human Rights
Cited by:
CitedAmin, Regina (on the Application of) v Secretary of State for the Home Department HL 16-Oct-2003
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 . .
CitedD, Regina (on the Application of) v Secretary of State for the Home Department (Inquest Intervening) CA 28-Feb-2006
The respondent appealed from orders made as to the conduct of an investigation into an attempted suicide in prison. The judge had severely criticised the appellant’s treatment of the case.
Held: The appeal failed. The court recited the . .
CitedReynolds, Regina (on the Application of) v Independent Police Complaints Commission and Another CA 22-Oct-2008
The court was asked to consider whether the IPCC could investigate the circumstances leading to the arrest of a suspect who fell into a coma after being arrested for being drunk. The IPCC appealed, saying that it did not have jurisdiction to . .
CitedSmith, Regina (on The Application of) v Secretary of State for Defence and Oxfordshire Assistant Deputy Coroner (Equality and Human Rights Commission intervening) SC 30-Jun-2010
The deceased soldier died of heat exhaustion whilst on active service in Iraq. It was said that he was owed a duty under human rights laws, and that any coroner’s inquest should be a fuller one to satisfy the state’s duty under Article 2.
CitedSecic v Croatia ECHR 31-May-2007
The applicant had been attacked and beaten by skinheads shouting racial abuse. He complained that as a Roma, the police had failed through race discrimination properly to investigate his complaint.
Held: The court repeated the statement that . .
CitedCommissioner of Police of The Metropolis v DSD and Another SC 21-Feb-2018
Two claimants had each been sexually assaulted by a later notorious, multiple rapist. Each had made complaints to police about their assaults but said that no effective steps had been taken to investigate the serious complaints.
Held: The . .

These lists may be incomplete.
Updated: 10 January 2021; Ref: scu.186853

Mulholland, Regina (on the Application of) v HM Coroner for St Pancras: Admn 16 Jan 2003

[2003] EWHC 96 (Admin)
Bailii
England and Wales
Citing:
See alsoRegina 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 by:
See AlsoRegina 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 . .

These lists may be incomplete.
Updated: 09 January 2021; Ref: scu.184628

Re Jordan: QBNI 6 Jan 2003

[2003] NIQB 1
Bailii
Northern Ireland
Citing:
See AlsoJordan, Re Application for Judicial Review (29) CANI 10-Sep-2004
. .
See AlsoJordan, Re Application for Judicial Review (30) CANI 10-Sep-2004
. .
See AlsoJordan, Re Application for Judicial Review QBNI 4-Sep-2001
An application was made for the production of documents by the police to support representations to be made on behalf of the family of the deceased to the coroner. The police requested but were refused undertakings as to their use. . .
CitedJordan, Re an Application for Judicial Review QBNI 12-Jan-2004
. .
CitedJordan, Re Application for Judicial Review CANI 12-Dec-2003
Appeal from a decision dismissing an application by Hugh Jordan for judicial review of the ‘continuing decision’ of the Director of Public Prosecutions for Northern Ireland refusing to give reasons other than in the most general terms for his . .
CitedJordan, Re Application for Judicial Review CANI 12-Sep-2003
The deceased had been shot by a sergeant of the RUC. The party sought to challenge a decision against the grant of legal aid. . .
CitedJordan, Re Application for Judicial Review CANI 28-May-2002
Whether the appeal against the decision of Kerr J dismissing the appellant’s applications for judicial review should be adjourned pending final determination of the proceedings in the English cases of R (Middleton) v HM Coroner for the Western . .
CitedRegina v Kansal (2) HL 29-Nov-2001
The prosecutor had lead and relied at trial on evidence obtained by compulsory questioning under the 1986 Act.
Held: In doing so the prosecutor was acting to give effect to section 433.
The decision in Lambert to disallow retrospective . .

Cited by:
CitedJordan, Re Application for Judicial Review (29) CANI 10-Sep-2004
. .
CitedJordan, Re Application for Judicial Review (30) CANI 10-Sep-2004
. .
CitedJordan, Re an Application for Judicial Review QBNI 12-Jan-2004
. .
See AlsoJordan, Re Application for Judicial Review CANI 12-Dec-2003
Appeal from a decision dismissing an application by Hugh Jordan for judicial review of the ‘continuing decision’ of the Director of Public Prosecutions for Northern Ireland refusing to give reasons other than in the most general terms for his . .
CitedJordan, Re Application for Judicial Review CANI 12-Sep-2003
The deceased had been shot by a sergeant of the RUC. The party sought to challenge a decision against the grant of legal aid. . .
See AlsoJordan, Re Application for Judicial Review CANI 28-May-2002
Whether the appeal against the decision of Kerr J dismissing the appellant’s applications for judicial review should be adjourned pending final determination of the proceedings in the English cases of R (Middleton) v HM Coroner for the Western . .
See AlsoJordan, Re Application for Judicial Review QBNI 4-Sep-2001
An application was made for the production of documents by the police to support representations to be made on behalf of the family of the deceased to the coroner. The police requested but were refused undertakings as to their use. . .

These lists may be incomplete.
Updated: 09 January 2021; Ref: scu.180279

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 died during a riot in Northern Ireland. He was under a hoarding run over by an armoured vehicle. Six years later an inquest had still not been held, civil proceedings remained pending, and an investigation by the Royal Ulster Constabulary found no basis for action.
Held: The Convention required by implication that there should be some form of effective official investigation when individuals have been killed as a result of the use of force. The failure to hold a proper inquiry into the death, was an infringement of the right to life under the Convention. The police officers investigating the incident were not independent of the officers implicated in the incident. There was however, no evidence which would entitle a conclusion that any deaths caused by the security services involved the unlawful or excessive use of force by members of the security forces, save where convictions had followed. The police had also in this case improperly put pressure on the applicant’s legal representatives with regard to evidence to be put before the court.
M Pellonpaa, President, and Judges Sir Nicolas Bratza, A. Pastor Ridruejo, J. Makarczyk, V. Straznicka, R. Maruste and S. Pavlovschi Section Registrar M. O’Boyle
Times 03-Jun-2002, 43290/98, [2002] ECHR 465, [2002] ECHR 469, (2002) 35 EHRR 593
Worldlii, Bailii
European Convention on Human Rights 2 34
Human Rights
Cited by:
CitedGentle, Regina (on the Application of) and Another v The Prime Minister and Another HL 9-Apr-2008
The appellants were mothers of two servicemen who had died whilst on active service in Iraq. They appealed refusal to grant a public inquiry. There had already been coroners inquests. They said that Article 2 had been infringed.
Held: The . .

These lists may be incomplete.
Updated: 08 January 2021; Ref: scu.172160

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: Coroners should be cautious of such adjournments. The jury would now deliver any verdict after a four month delay. The deceased had been involved in a struggle in the station, and lost consciousness, but had not been put in the recovery position for some time. Neglect in coroners’ cases meant failing to take an opportunity to avoid a death. However there was no evidence to support any conclusion that a relationship of causation existed to support a verdict of neglect.
Mr Justice Richards
[2002] EWHC 302 (Admin)
Bailii
European Convention on Human Rights
England and Wales
Citing:
CitedRegina 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 . .
CitedRegina v Galbraith CCA 1981
Rejection of Submission of No Case to Answer
The defendant had faced a charge of affray. The court having rejected his submission of having no case to answer, he had made an exculpatory statement from the dock. He appealed against his conviction.
Held: Lord Lane LCJ said: ‘How then . .
CitedRegina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
CitedRegina (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 . .
CitedRegina (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 . .
CitedNicholls v Coroner for City of Liverpool Admn 8-Nov-2001
As the deceased was arrested he swallowed something. He was examined by a doctor and denied that he had swallowed drugs, but his condition deteriorated and he died at hospital. The coroner refused to admit the evidence of a professor who was highly . .
CitedRegina (Dawson) v HM Coroner for East Riding and Kingston upon Hull Admn 2001
. .

These lists may be incomplete.
Updated: 08 January 2021; Ref: scu.168731

Regina v Lincoln Coroner, Ex Parte Hay: Admn 19 Feb 1999

Coroners Society recommended to publish pre-trial guidelines and prepare a list of witnesses to be called showing in each case a brief summary of the evidence expected to be given by that witness in order to assist parties at inquests. A costs order might be made against a coroner when: (1) If a coroner not only filed an affidavit but also appeared and contested the making of an adverse order in an inter partes adversarial mode, then he or she was at risk as to costs; (2) If on the other hand, the coroner, as was fitting for somebody holding judicial office, swore an affidavit to assist the court and then appeared in court, more in the role of an amicus rather than as a contesting party, then the court was likely to follow the normal rule set out in Jervis and make no order as to costs provided that it did not express strong disapproval of his or her conduct.
Brooke LJ said: ‘We are unwilling for our part, to fetter the discretion of a coroner by being at all prescriptive about the procedures he should adopt in order to achieve a full, fair and thorough hearing.’
Forbes J, Brooke LJ
Times 30-Mar-1999, [1999] EWHC Admin 155, [2000] Lloyd’s Med LR 264
Bailii
Citing:
DoubtdRegina v Coroner for Wiltshire ex parte Clegg QBD 1996
The court awarded costs against a coroner on an appeal even though he had only taken part by the filing of an affidavit. . .
[1996] 161 JPR 521

Cited by:
CitedRegina on the Application of Christine Davies (No 2) v HM Deputy Coroner for Birmingham CA 27-Feb-2004
The claimant appealed against a costs order. She had previously appealed against an order of the High Court on her application for judicial review of the inquest held by the respondent.
Held: The coroner, and others in a similar position . .
[2004] EWCA Civ 207, Times 10-Mar-04, [2004] 3 All ER 543, [2004] 4 Costs LR 545, [2004] 1 WLR 2739, [2004] Inquest LR 96, (2004) 80 BMLR 48
DoubtedRegina v Her Majesty’s Coroner for Inner London North ex parte Peter Francis Touche CA 21-Mar-2001
The applicant’s wife had died of a cerebral haemorrhage, the result of severe hypertension, possibly secondary to eclampsia. The coroner decided not to hold an inquest. The issue raised was whether he was required to hold an inquest because there . .
Gazette 17-May-01, [2001] EWCA Civ 383, [2001] QB 1206
CitedSreedharan, Regina (on The Application of) v HM Coroner for The County of Greater Manchester Admn 28-May-2012
The claimant doctor renewed his application for judicial review of the jury verdict of unlawful killing at the inquest into a patient. The patientwas alcoholic. The doctor prescribed a sedative drug for him, but it was known to be potentially lethal . .
[2012] EWHC 1386 (Admin)

These lists may be incomplete.
Updated: 18 December 2020; Ref: scu.85369

Case 22 H 6, 51 12 E 4, Ch 1 13 E 4, 6 Process, Viscount By The Judges of Both Benches Co Lit 157 B Hob 139: 1220

In case of the death or removal of a sheriff before the end of his year; no new process shall issue until a new sheriff is made, but shall wait till then, and not be directed to the coroners : but if issue be joined, and the plaintiff suggests to the court that the sheriff is his cousin, and the defendant does not deny it ; process shall issue to the coroners to speed the suit. So if it be suggested in Chancery, and not denied by the other party, that the sheriff is plaintiff, or defendant in the suit; the writ shall be directed by the coroners. [*By the statutes of 12 E. 4, ch. 1, and 17 E. 4, ch. 6, after the end of Michaelmas and Hillary terms, no writ or process shall be directed to the old sheriff, for the sheriff is not to continue in his office any longer. ] Where a sheriff makes a false or insufficient return, he shall be fined or amerced, as the case requires : but notwithstanding these misdemanours, the writ shall continue to be directed to him, and not to the coroners.
[1220] EngR 335, (1220-1623) Jenk 99, (1220) 145 ER 71 (A)
Commonlii

Updated: 16 December 2020; Ref: scu.461247

Regina (Pereira) v Inner South London Coroner and Others: QBD 14 Jun 2007

The applicant sought to challenge a decision to adjourn an inquest.
Held: A decision as to whether an inquest should be adjourned was one within the coroner’s discretion. Provided he had acted rationally and taken into account the relevant factors, his decision could not be challenged by way of judical review.
Laws LJ, Mitting J
Times 22-Jun-2007
England and Wales

Updated: 15 December 2020; Ref: scu.263550

A and Another v Inner South London Coroner: QBD 24 Jun 2004

At an inquest into the death of a civilian apparently shot by police officers, the officers applied for anonymity, which the coroner refused. They sought judicial review.
Held: How witnesses participated in coroners inquests was to be decided on a case by case basis. A witness seeking anonymity had to establish both a subjective fear and reasonable objective grounds. Once those were established, the court could carry out a balancing exercise. In this case the coroner had failed to ask the two first questions together. In this case the request was that anonimity be preserved until the announcement of the verdict. This would protect the officers’ families and seemed to meet the demands of justice.
Mitting J
Times 12-Jul-2004
England and Wales
Citing:
CitedA and Others, Regina (on the Application of) v Lord Saville of Newdigate and others CA 28-Jul-1999
Former soldiers who had been involved in the events in Londonderry in 1972, and were to be called to give evidence before a tribunal of inquiry, still had cause to fear from their names being given, and so were entitled to anonymity when giving such . .
Times 29-Jul-99, [1999] EWCA Civ 3012, [2000] 1 WLR 1855, [1999] 4 All ER 860
CitedRegina v Governor of Pentonville Prison, Ex parte Fernandez: Fernandez v Government of Singapore HL 1971
Test for police protection need
The court considered the degree of risk to an individual which should give rise to a duty on the police to protect him under article 2.
Held: Lord Diplock said: ‘My Lords, bearing in mind the relative gravity of the consequences of the court’s . .
[1971] 1 WLR 987, [1971] 2 All ER 691
Appealed toRegina (A and Another) v Inner South London Coroner CA 2-Nov-2004
Police officers sought anonymity when asked to appear before a coroner’s court, citing fear of violence if named. The family of the deceased appealed an order granting that to them.
Held: The coroner had heard evidence that a family member had . .
Times 11-Nov-04

Cited by:
Appeal fromRegina (A and Another) v Inner South London Coroner CA 2-Nov-2004
Police officers sought anonymity when asked to appear before a coroner’s court, citing fear of violence if named. The family of the deceased appealed an order granting that to them.
Held: The coroner had heard evidence that a family member had . .
Times 11-Nov-04

These lists may be incomplete.
Updated: 15 December 2020; Ref: scu.199972

Regina v Shrewsbury Coroner’s Court ex parte British Parachute Association: QBD 21 Sep 1987

Coroners are forbidden by the rules to make recommendations to a jury as to their verdict. Despite the fact that the coroner was represented at the appeal, the court refused to make any order for costs against the coroner. This was not a case where they could express strong disapproval of the coroner, there being no special circumstances .
Lloyd LJ and Mann J
(1987) 152 JPR 123, Times 21-Sep-1987
Coroners Rules 1984 (1984 No 552) 36(2)
England and Wales
Cited by:
CitedRegina on the Application of Christine Davies (No 2) v HM Deputy Coroner for Birmingham CA 27-Feb-2004
The claimant appealed against a costs order. She had previously appealed against an order of the High Court on her application for judicial review of the inquest held by the respondent.
Held: The coroner, and others in a similar position . .
[2004] EWCA Civ 207, Times 10-Mar-04, [2004] 3 All ER 543, [2004] 4 Costs LR 545, [2004] 1 WLR 2739, [2004] Inquest LR 96, (2004) 80 BMLR 48

These lists may be incomplete.
Updated: 15 December 2020; Ref: scu.194541

Smith v Director of Public Prosecutions and Another: QBD 28 Jul 1999

Whilst there is no absolute rule of law requiring a delay in a road traffic case involving death pending the results of a coroner’s inquest, in practice they should do so, and make appropriate enquiries as to the stage reached by the inquest. Nevertheless, in this case, being unaware of the true position and having proceeded in ignorance of it, the trial decision must stand.
Times 28-Jul-1999, Gazette 08-Sep-1999
England and Wales

Updated: 14 December 2020; Ref: scu.89331

Regina (A and Another) v Inner South London Coroner: CA 2 Nov 2004

Police officers sought anonymity when asked to appear before a coroner’s court, citing fear of violence if named. The family of the deceased appealed an order granting that to them.
Held: The coroner had heard evidence that a family member had told the officers they would be at risk if a verdict of unlawful killing was not returned. The decision by the coroner not to grant anonymity was a mistake.
Times 11-Nov-2004
England and Wales
Citing:

  • Appeal from – A and Another v Inner South London Coroner QBD 24-Jun-2004
    At an inquest into the death of a civilian apparently shot by police officers, the officers applied for anonymity, which the coroner refused. They sought judicial review.
    Held: How witnesses participated in coroners inquests was to be decided . .
    Times 12-Jul-04
  • Cited – A and Others, Regina (on the Application of) v Lord Saville of Newdigate and others CA 28-Jul-1999
    Former soldiers who had been involved in the events in Londonderry in 1972, and were to be called to give evidence before a tribunal of inquiry, still had cause to fear from their names being given, and so were entitled to anonymity when giving such . .
    Times 29-Jul-99, [1999] EWCA Civ 3012, [2000] 1 WLR 1855, [1999] 4 All ER 860

Cited by:

  • Appealed to – A and Another v Inner South London Coroner QBD 24-Jun-2004
    At an inquest into the death of a civilian apparently shot by police officers, the officers applied for anonymity, which the coroner refused. They sought judicial review.
    Held: How witnesses participated in coroners inquests was to be decided . .
    Times 12-Jul-04

These lists may be incomplete.
Updated: 10 December 2020; Ref: scu.219421

Regina v Greater Manchester Council ex parte Worch: 1988

The court considered to what extent it could look to the form of an Act before it was amended in order to assist it in construing the Act as amended: ‘The original section 21(a) of the [Coroners (Amendment) Act] 1926 is no longer law, since it has been replaced by Section 23(3) of the Births and Deaths Registration Act 1953. Nevertheless, the original subsection is admissible in construing the section as a whole and, in our judgment, throws light on its construction. It demonstrates that the section as a whole contemplates a two-stage process’.
Slade LJ
[1988] 1 QB 513
Births and Deaths Registration Act 1953
England and Wales
Cited by:

These lists may be incomplete.
Updated: 02 December 2020; Ref: scu.238299

Regina v Birmingham Coroner, ex parte Cotton: QBD 1995

The Coroner’s court is not the proper place to explore questions of clinical negligence.
[1995] 160 JP 12
England and Wales
Cited by:

  • 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 . .
    [1996] EWHC Admin 307

These lists may be incomplete.
Updated: 02 December 2020; Ref: scu.237543

Regina (Cash) v County of Northamptonshire Coroner: Admn 2007

References: [2007] EWHC 1354 (Admin)
Judges: Keith J
Jurisdiction: England and Wales
This case is cited by:

  • Cited – P, Regina (on The Application of) v HM Coroner for The District of Avon CA 18-Dec-2009
    p_coroneravonCA2009
    The deceased was found hanging in her prison cell. The jury returned a verdict of accidental death, not being satisfied that she was not merely making a cry for help. The family appealed a finding that the inquest had satisfied the requirement for a . .
    (, [2009] EWCA Civ 1367)

These lists may be incomplete.
Last Update: 27 November 2020; Ref: scu.384385

Regina v South London Coroner ex parte Ruddock: CA 8 Jul 1982

‘The coroner’s task in a case such as this is a formidable one . . 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 the 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 prosecution accuses and the accused defends, the judge holding the balance or the ring, whichever metaphor one chooses to use’.
References: Unreported, 8 July 1982
Judges: Lord Lane CJ
Jurisdiction: England and Wales

Last Update: 21 November 2020; Ref: scu.224067

Terry v Coroner for East Sussex: QBD 12 Jan 2001

A coroner having issued a death certificate following a post mortem, but without an inquest, had power, upon later receiving powerful new evidence, himself to re-open the case, and to order an inquest, and he did not first have to seek authority from the High Court. The issuing of the certificate did not make him functus officio. The need for certainty meant that such power should only be used when the evidence was powerful, and until then the certificate created a rebuttable presumption. In this case the coroner had asked himself the proper questions, and answered the reasonably, and his decision not to hold an inquest could not be challenged..
References: Times 12-Jan-2001
Statutes: Coroners Act 1988
This case is cited by:

  • Appeal from – Terry v Coroner for East Sussex CA 12-Jul-2001
    The issue of a certificate to the Registrar of Deaths by a coroner, after a post mortem, but on the basis that an inquest was then thought unnecessary, did not make him functus officio. The procedure under the section did not replace the scheme for . .
    (Times 26-Jul-01, Gazette 06-Sep-01)

These lists may be incomplete.
Last Update: 21 November 2020; Ref: scu.89769

Regina v Greater Belfast Coroner, ex parte Northern Ireland Human Rights Commission: CANI 11 May 2001

The Commission was a creation of statute, and had not been given power to intervene in judicial proceedings. The coroner was investigating deaths at Omagh from a terrorist bombing, and the Commission sought to intervene. The Act should not be read restrictively, but nor could provisions be read into it which did not exist at will. The Commission had its own powers to commence investigations. When it might become involved in proceedings, either it sought to influence the outcome or it did not. If it did not, it was an improper distraction, and if it did it would be an improper intrusion, threatening the appearance of independence of the judiciary. In either case costs would be increased and have to be paid, and new issues of equality of arms would arise.
References: Times 11-May-2001
Statutes: Northern Ireland Act 1998

Last Update: 21 November 2020; Ref: scu.88484

Regina v Coroner for Kent Ex Parte Johnstone: QBD 12 Sep 1994

A coroner may be liable for costs after a wrongful refusal of an adjournment. A mistake by a medical expert caused the need for a new inquest. A request that the coroner should pay the applicant’s costs was granted. The court identified why the order should be made: (1) Although it was not a case which called for strong disapproval of the coroner’s actions, the court had attached some measure of blame to him; (2) More importantly, he had sought to defeat the challenge to his decisions, and was certainly not represented in the role of amicus curiae, or anything of that nature. He would no doubt have been seeking his costs and would have been entitled to them if he had won; (3) The applicant was not legally aided; (4) The court was unable to recognise any principle that said that in these circumstances some special protection should be give to the coroner.
References: Ind Summary 12-Sep-1994, Times 19-Oct-1994, [1995] 6 Med LR 116
Judges: McCowan LJ and Buxton J
This case is cited by:

  • Cited – Regina on the Application of Christine Davies (No 2) v HM Deputy Coroner for Birmingham CA 27-Feb-2004
    The claimant appealed against a costs order. She had previously appealed against an order of the High Court on her application for judicial review of the inquest held by the respondent.
    Held: The coroner, and others in a similar position . .
    (, [2004] EWCA Civ 207, Times 10-Mar-04, [2004] 3 All ER 543, [2004] 4 Costs LR 545, [2004] 1 WLR 2739, [2004] Inquest LR 96, (2004) 80 BMLR 48)

These lists may be incomplete.
Last Update: 21 November 2020; Ref: scu.86440

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 been in custody and a verdict of accidental death was returned.
Held: The Court could not be satisfied that enough had been done to ascertain whether there was a traumatic cause to the deterioration of the deceased which took place while he was in a police cell. The court felt unable to determine whether a different verdict would emerge from a fresh inquest, but because the inquiry had been inadequate a fresh inquest was ordered. A failure to resolve discrepancies in papers required a new inquest. There should be a new inquest with consideration being given to the question of neglect, where there was new evidence (which had not been investigated at the inquest) which could support a different verdict; and that in the circumstances it was necessary and desirable in the interests of justice that the inquisition be quashed and a new inquest held.
References: Times 03-Apr-1996, [1996] 35 BMLR 48, (1996) COD
Judges: Newman J
Statutes: Coroners Act 1988 13
This case cites:

  • 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 . .
    (Times 23-Jul-93, Ind Summary 18-Oct-93, Ind Summary 06-Sep-93, Guardian 12-Jul-93)

This case is 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 . .
    (, [2003] EWHC 2612 (Admin))
  • 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 . .
    (, [2004] EWHC 3071 (Admin))

These lists may be incomplete.
Last Update: 21 November 2020; Ref: scu.84476

Regina v Avon Coroner, Ex Parte Bentley: QBD 23 Mar 2001

The coroner refused to allow access to the sister of the deceased subject of the inquest to the papers and statements in advance of the inquest. The fact that the rules allowed it but impose do clear duty did not mean that he should not look to the circumstances of the case, and recognise the unfairness of disallowing advance disclosure to those representing the relatives.
References: Times 23-Mar-2001
Statutes: Coroners Rules 1984 (1984 No 552) 57(1)
Jurisdiction: England and Wales

Last Update: 14 November 2020; Ref: scu.88374

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 such a conclusion is only permissible if it has been proved to the criminal standard of proof (i.e. so that the coroner or jury is sure that the deceased did an act which was intended to and did cause his or her own death).
Held: The claim failed.
There is a logical difficulty: ‘A narrative conclusion to the effect that on the balance of probabilities the deceased did a deliberate act which caused his own death intending the outcome to be fatal clearly amounts to a conclusion that the deceased committed suicide whether or not the word ‘suicide’ is used. It is sophistry to say that such a conclusion is not one of suicide because the required standard of proof has not been met. The standard of proof even if referred to in the record of inquest, as it was in this case, is not itself part of the substantive conclusion adopted by the coroner or jury. It is simply a statement of the evidential test which must be met in order to reach a particular conclusion. If the standard of proof required to determine that the deceased committed suicide is the criminal standard and the necessary facts have been proved only on the balance of probabilities, this does not mean that a conclusion which records those facts is not one of suicide. It means that the coroner or jury cannot lawfully reach that conclusion.’
‘We consider the true position to be that the standard of proof required for a conclusion of suicide, whether recorded in short-form or as a narrative statement, is the balance of probabilities, bearing in mind that such a conclusion should only be reached if there is sufficient evidence to justify it.’
References: [2018] EWHC 1955 (Admin), [2018] Inquest LR 225, [2018] ACD 105, [2019] 1 All ER 561
Links: Bailii
Judges: Leggatt LJ, Nicol J
Statutes: Coroners and Justice Act 2009
Jurisdiction: England and Wales
This case is cited by:

  • At First Instance – Maughan, Regina (on The Application of) v Her Majesty’s Senior Coroner for Oxfordshire CA 10-May-2019 (, [2019] EWCA Civ 809, [2019] 3 All ER 567, [2019] 3 WLR 365, [2019] Med LR 325, [2019] QB 1218, [2019] WLR(D) 271, )
    Questions of importance concerning the law and practice of coroners’ inquests where an issue is raised as to whether the deceased died by suicide. The questions can be formulated as follows:
    (1) Is the standard of proof to be applied the . .
  • At Admn – Maughan, Regina (on The Application of) v Her Majesty’s Senior Coroner for Oxfordshire SC 13-Nov-2020 (, [2020] UKSC 46, , )
    ‘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 . .

These lists may be incomplete.
Last Update: 14 November 2020; Ref: scu.620653

Re Jordan: Misc 5 Dec 2016

References: [2016] NICoroner 3
Links: Bailii
Judges: Horner J
Statutes: Justice (NI) Act 2002 35(3)
Jurisdiction: Northern Ireland
This case cites:

This case is cited by:

  • See Also – Re Jordan Misc 21-Nov-2016 (, [2016] NICoroner 2)
    . .

These lists may be incomplete.
Last Update: 05 November 2020; Ref: scu.581147