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

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

Lists of cited by and citing cases may be incomplete.

Coroners

Updated: 01 November 2021; Ref: scu.408663

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

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

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

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

[2016] EWHC 1726 (Admin)
Bailii
England and Wales

Updated: 24 July 2021; Ref: scu.567204

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

References: [1982] 126 SJ 625
Coram: Lord Lane CJ
Ratio: The court discussed the function of the coroner and his inquest.
Lord Lane CJ said: ‘The coroner’s task in a case such as this is a formidable one, and no one would dispute that; that is quite apart from the difficulties which inevitably arise when feelings are running high and the spectators are emotionally involved and vocal. Once again it should not be forgotten that an inquest is a fact finding exercise and not a method of apportioning guilt. The procedure and rules of evidence which are suitable for one are unsuitable for the other. In an inquest it should never be forgotten that there are no parties, there is no indictment, there is no prosecution, there is no defence, there is no trial, simply an attempt to establish facts. It is an inquisitorial process, a process of investigation quite unlike a criminal trial where the prosecutor accuses and the accused defends, the judge holding the balance or the reins whichever metaphor one chooses to use.’
and ‘the function of an inquest is to seek out and record as many of the facts concerning the death as [the] public interest requires.’ The Broderick Committee exhaustively considered the role of the coroner’s inquest in modern society. The committee identified the following grounds of public interest which they believed that a coroner’s inquiry should serve:
(1) To determine the medical cause of death;
(ii) To allay such rumours or suspicion;
(iii) to draw attention to the existence of circumstances which, if unremedied, might lead to further deaths;
To advance medical knowledge;
(v) To preserve the legal inteersts of the deceased person’s family, heirs or other interested parties.
However ‘It is not the function of the Coroner’s inquest to provide a forum for attempts to gather evidence for pending or future criminal or civil proceedings.”
This case is cited by:

• Cited – In the Matter of Captain Christopher John Kelly Admn (Bailii, [1996] EWHC Admin 15)
  The deceased was killed by ‘friendly fire’ during a night exercise in Kenya. A verdict of accidental death was returned, and a fresh inquest was sought particularly in the light of a statement from a fellow officer.
  Held: The emergence of . .
• Cited – In Re Neal (Coroner: Jury) QBD (Times 09-Dec-95, [1995] 37 BMLR 164)
  The father of the deceased sought to have the coroner quash the inquest. His daughter had died in Spain from carbon monoxide poisoning, apparently emanated from a faulty water heater in the apartment in which she had stayed. Her body had been . .
• Cited – Assistant Deputy Coroner of Inner West London v Paul and Another, Regina on the Application of CA (Bailii, [2007] EWCA Civ 1259, Times 11-Dec-07, [2007] Inquest LR 270, [2008] 1 All ER 981, [2008] 1 WLR 1335)
  The coroner appealed a judicial review granted after he allowed into evidence, hearsay evidence contained in a written statemnent from a witness who could not attend the inquest.
  Held: Rule 37 does not allow the admission of a document, even . .
• Cited – Hurst, Regina (on the Application of) v Commissioner of Police of the Metropolis v London Northern District Coroner HL (Bailii, [2007] UKHL 13, [2007] 2 WLR 726, [2007] 2 All ER 1025, [2007] 2 AC 189)
  The claimant’s son had been stabbed to death. She challenged the refusal of the coroner to continue with the inquest with a view to examining the responsibility of any of the police in having failed to protect him.
  Held: The question amounted . .
• Cited – O’Connor, Regina (On the Application of) v HM Coroner for District of Avon and Another Admn (Bailii, [2009] EWHC 854 (Admin))
  Two children died when their father jumped with them from a hotel balcony. The father had been acquitted in Crete of manslaughter after evidence of his psychiatric condition. The applicant now challenged the English coroner’s verdict of unlawful . .
• Cited – Wilkinson, Regina (on The Application of) v HM Coroner for The Greater Manchester South District Admn (Bailii, [2012] EWHC 2755 (Admin), [2012] WLR(D) 274, WLRD)
  The court was asked whether evidence of the commission of the criminal offence of causing death by careless driving contrary to section 2B of the 1988 Act is capable of justifying a verdict of ‘unlawful killing’ at an inquest.
  Held: The . .
• Approved – McKerr v Armagh Coroner HL ([1990] 1 WLR 649, [1990] 1 All ER 865)
  It is for the coroner to decide how to adduce the necessary evidence as to death. Lord Goff discussed Rule 17 of the 1980 Rules: ‘Nor, in my opinion, does the mere fact that a rule restricts the power of a coroner as to the evidence which he may . .
• Cited – Secretary of State for Foreign & Commonwealth Affairs v Assistant Deputy Coroner for Inner North London Admn (Bailii, [2013] EWHC 1786 (Admin), [2013] WLR(D) 261, WLRD)
  The coroner was to hold an inquest into the death of Alexander Litvinenko, a prominent Russian exile. The Secretary of State issued a public interest immunity certificate in respect of several documents sought for the inquest, which, in part, the . .

(This list may be incomplete)

Last Update: 28-Aug-16
Ref: 187755

References: Unreported, 19 February 1987
This case is cited by:

• Cited – Sutovic, Regina (on the Application Of) -v- HM Coroner for North London Admn (Bailii, [2006] EWHC 1095 (Admin))
  The court heard an application for judicial review of the Coroner’s verdict, on the grounds of procedural irregularity and insufficiency of enquiry. The claimant also sought a new review in the light of more recently received evidence.
  Held: . .
• Cited – Jones -v- HM Coroner for The Southern District of Greater London and Another Admn (Bailii, [2010] EWHC 931 (Admin), [2010] Inquest LR 80)
  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 . .