Abstract
Disclosure
Although material should be disclosed to the coroner, it is for him to decide whether to make further disclosure to the parties, if there are competing public interests. Assistant Deputy Coroner for Inner West London v Channel 4 Television [2007] EWHC 2513 (QB).
Absent witness
A witness living abroad is not compellable but his statement may be read by the coroner to the jury if “unlikely to be disputed”. R (Paul) v Assistant Deputy Coroner Inner West London [2007] EWCA Civ 1259, (2008) 1 WLR 1335, [2008] 1 All ER 981.
Jury
The deceased had taken an overdose of unlawful drugs, the police were called, they found it necessary to use force to restrain him, and in the course of the restraint he collapsed and died. The verdict should have been left to the jury. R (Cash) v County of Northamptonshire Coroner [2007] EWHC 1354 (Admin), [2007] 4 All ER 903.
Article 2
Where there is death in state custody or detention, e.g. a compulsory mental health patient, Article 2 is engaged. R (Allen) v HM Coroner Inner North London [2009] EWCA Civ 623.
Adjourn
Having adjourned an inquest because of criminal proceedings, which result in a conviction of D for murder or manslaughter of the deceased, the coroner may well be justified in refusing thereafter to resume the inquest, because the cause of death will have been established and it is no function of the inquest to investigate civil liability. R (Hurst) v London North District Coroner [2007] UKHL 13, [2007] 2 AC 189.
Adjourn
In a case involving killing by the police, the Crown Prosecution Service asked the coroner to adjourn the inquest pending criminal proceedings, which he did. He should do so unless in his discretion he determines that there is “reason to the contrary”. R (Pereira) v Inner South London Coroner [2007] EWHC 1723 (Admin), [2007] 1 WLR 3257.
Liability
A finding of fact might indicate an unlawful or criminal killing, but unlawful killing is not an acceptable verdict, as it goes to liability: Jordan v Lord Chancellor [2007] UKHL 14, [2007] 2 AC 226. Such matters should be reported by the coroner to the appropriate authorities.
Unlawful killing
In Greece on holiday the father threw his son off a balcony and the son died. The father was tried for homicide in a Greek court and acquitted on the basis of psychosis. In such circumstances the coroner in England, before making a finding of unlawful killing, should be satisfied that insanity has been disproved as it would have been in an English court. A narrative verdict might be more appropriate. R (O'Conner) v Avon Coroner [2009] EWHC 854 (Admin), [2010] 2 WLR 1299.
Liability
A soldier died in Iraq, apparently from a combination of excessive heat and hypothermia. An inquest was required, Article 2; full disclosure should have been made to the coroner; a robust finding of failure to support a soldier to adjust to the climate did not constitute a finding of liability. R (Trinity Mirror PLC) v Croydon Crown Court [2008] EWCA Crim 50, [2008] QB 770. R (Smith) Oxfordshire Assistant Deputy Coroner [2009] EWCA Civ 441.
Police
The police must notify the coroner of any death coming to their attention and disclose the information they have. Jordan v Lord Chancellor [2007] UKHL 14, [2007] 2 AC 226, paras 42–45.
Hospital
The deceased died in the course of an operation in hospital. The coroner called a pathologist and the hospital consultant but refused to call an expert on behalf of the family. Held, the coroner was justified as his duty was to investigate the cause of death and not to embark upon liability issues. A death in hospital, which might give rise to civil negligence issues, does not require the same intense investigations as a death in custody. R (Goodson) v Bedfordshire and Luton Coroner [2004] EWHC 2931 (Admin), [2006] 1 WLR 432. R (Takoushis) v Inner North London Coroner [2005] EWCA Civ 1440, [2006] 1 WLR 461.
A schizophrenic who had threatened suicide, and been taken to hospital, left the hospital and committed suicide. The coroner should fully investigate the situation and in the case of a health and safety risk he should summon a jury. R (Takoushis) v Inner North London Coroner [2005] EWCA Civ 1440, [2006] 1 WLR 461.
Death in nursing home
The death of an old person suffering from mental health problems in a nursing home led to a critical report by inspectors relating to drug treatment and similar matters. Held: evidence of a possible unnatural death requiring an inquest. R (Bicknell) v HM Coroner for Birmingham and Solihull [2007] EWHC 2547 (Admin).
Public inquiry
The deceased, 16 years old, was sentenced to detention and committed suicide in custody. The inquest found accidental death and indicated that the death had been contributed to by failure to recognize the risk and to take appropriate precautions. The coroner recommended a public inquiry, the Secretary of State refused. Held: a reasonable and lawful refusal. R (Scholes) v Secretary of State for the Home Department [2006] EWCA Civ 1343, [2006] HRLR 44.
Blame
The deceased was found hanging in his cell in prison (Young Offenders Institution). The staff did not have the necessary equipment and training for dealing with such a situation. Although not in the “blame game”, the coroner should investigate and report on such matters. R (Lewis) v HM Coroner for Mid and North Shropshire [2009] EWCA Civ 1403.
Relevant issues
The coroner need not investigate every issue raised, provided that he does properly consider the principal relevant issues. Issues were raised about food in the airway, resuscitation and the competence of the resuscitation team. The coroner had considered the first two, not the third, but though it might have been better to investigate that too, nonetheless it had not contributed to the death. R (Allen) v HM Coroner Inner North London [2009] EWCA Civ 623.
Those remarks
Required to determine how the deceased died, the coroner should avoid any irrelevant or unnecessary or unfair or offensive remarks about anybody, including solicitors. Such remarks can be declared unlawful by the court. R (Farah) v HM Coroner for Southampton [2009] EWHC 1605 (Admin), Coroners Act 2009, s 5.