Healthcare - March 2010

A case law digest - Coronial Law

Not only will 2009 be remembered as “the year” that paved the way for the first major reform of the coronial system for over 100 years, it will also be remembered for the number of cases that came before the Courts, for clarification on the roles and powers of Coroners and Juries alike.  In this case digest we review the cases and outcomes which should of interest. 

R (on the application of Butler) v HM Coroner for the Black Country District - 21 January 2010
Whilst a coroner's powers as to the scope of investigation during an inquest were wide, they were not unlimited. Where a forthcoming inquest was to be in the "traditional" style, involving consideration of the means by which the deceased came to his death, rather than issues of accountability or responsibility for the death, the coroner had adopted an unlawfully wide approach in indicating that evidence from police officers and health and safety evidence should be adduced and that a verdict of unlawful killing could properly be left to the jury.

R (on the application of P) v HM Coroner for the District of Avon - 18 December 2009
Where a coroner had directed the jury as to the availability of two short form verdicts and a narrative verdict, a failure to direct the jury expressly that a narrative summary could be appended to a short form verdict had rendered the summing up materially defective because the jury had effectively been disabled from fulfilling the purposes referred to in R (on the application of Amin (Imtiaz)) v Secretary of State for the Home Department (2003) UKHL 51, (2004) 1 AC 653.

Comment: The case is a reminder that the coroner’s first task is “to decide how best, in a particular case, to elicit the jury’s conclusion on the central issue or issues.” Furthermore, that since the case of Middleton, there had been no legal impediment to a verdict of either suicide or accident having a narrative appended to it. 

R (on the application of Dowler) v HM Coroner for North London – 6 November 2009
It was appropriate, pursuant to the Coroners Act 1988 s.13, for a coroner's inquest to be quashed and for a new inquest to be held before a different coroner where a number of breaches of the Coroners Rules 1984 had occurred, and where criticisms of a general practitioner made by the coroner meant that it was inappropriate for the same coroner to hear the new inquest.

R (on the application of Farah) v HM Coroner for Southampton & New Forest District of Hampshire - 3 July 2009
The court considered the right of a coroner to express opinions on matters not relating to the circumstances in which a deceased person had died and it gave guidance on a court's jurisdiction to declare such comments unlawful.

A coroner sitting without a jury was entitled to give a verdict and a judgment dealing with the stipulated issues of who the deceased was, how, when and by what means, in what circumstances and where the deceased came by his death.  Whilst the court had jurisdiction to declare comments made by a coroner unlawful, the power was to be used sparingly and comments which did not relate to any of the stipulated issues in any way, were matters of opinion and were sufficiently unfairly critical and offensive to any party as to justify the intervention of the courts. 

Comment: There is therefore a remedy in the event of gratuitous and offensive comments being made by a coroner. 

R (on the application of Ralph Allen) v HM Coroner for Inner North London & Camden & Islington Mental Health Trust & Social Care NHS Foundation Trust - 25 June 2009
An investigation under the European Convention on Human Rights 1950 art.2 was triggered where the death of a mental health patient who had been detained by the state raised issues as to whether the medical authorities had failed in their obligation to take general measures to save her from dying and whether the death was  caused by a breach of the operational obligations to take steps to save the patient from death. In the circumstances, the investigation into the death undertaken by a coroner could not be criticised.

Comment: The court considered that the Article “was not only engaged in cases where there were fundamental failures that caused the condition itself that caused the death.”

R (on the application of Ahmed) v HM Coroner South East & Cumbria - 11 June 2009
A coroner had been entitled not to disclose material prior to an inquest into the death of a 17 year old girl when there was an ongoing criminal investigation. Although it would have been preferable for a degree of disclosure to have been made, it was a matter of discretion for the coroner.

Comment: The Judge also commented that, had a sensible request (for disclosure) been made, the coroner would have given real consideration to releasing whatever material seemed appropriate, but no such request was made, and is worth keeping in mind when requests advance disclosure of material are made. 

R (on the application of Christine O’Connor) v HM Coroner for Avon - 7 May 2009
A coroner had proceeded on a material misdirection of the law in viewing the test for unlawful killing to be objective and for considering the defence of insanity as not relevant to his verdict. Further, with regard to insanity, the differences between a coroner's inquest and a criminal trial necessitated a different standard of proof. Insanity, properly raised, had to be disproved to the criminal standard to sustain a verdict of unlawful killing.

Comment: The case is useful authority when looking at the test to be applied for a verdict of unlawful killing to be returned.  The Court held that a coroner’s verdict of unlawful killing necessarily predicated a finding equivalent to that required for a conviction of at least manslaughter in a criminal trial.  A conclusion of unlawful killing could not be reached unless the coroner was so satisfied to the criminal standard of proof.  The differences between coroner’s inquest and a criminal trial necessitated different standards of proof.

The case is also useful reminder that in an inquest there are no parties, indictments, prosecution, defence or trial and the procedure at an inquest did not accord a would-be defendant the safeguards that he would have at a criminal trial. 

Roach v Home Office – 25 February 2010
Costs of attendance at an inquest were capable of being recoverable as costs incidental to subsequent civil proceedings.

Kiran Bhogal, Partner
Weightmans LLP