CHAPTER ONE – THE BACKGROUND TO AN INQUEST
SOURCES OF LAW AND PROCEDURE
The morning of 25 July 2013 heralded the coming into force of a ground-breaking piece of legislation in the history of inquest law: the Coroners and Justice Act 2009 (“the 2009 Act”). It is that statute which continues to govern inquest law today, some ten years later. Its predecessor was the Coroners Act 1988 which, despite the similarity in name, was in fact a consolidating Act pulling together statutes from the 19th Century, rather than the coherent piece of legislation which the 2009 Act promised to be. Before the 1988 Act was the 1887 Act, which itself was a consolidation of a number of ancient statutes passed mainly in the reigns of Edward I, Edward III and Henry VIII.
The 2009 Act was long overdue in the opinion of many: there had been decades of discontent which would bubble over into loud calls for reform of the coronial system. For example:
- The killing of anti-racist campaigner Blair Peach in 1979 was alleged by witnesses to have been caused by a police officer. At least one pathologist concluded that the injury to Peach’s skull could have been caused by a lead-weighted cosh or police radio. An internal police investigation concluded that Peach was almost certainly killed by a police officer. That report was never disclosed to the inquest into Peach’s death; it was only released 31 years later. As a result, at least partially, the inquest that had taken place found the death was caused by ‘misadventure’;
- The report of the Stephen Lawrence Inquiry – a landmark report in many ways – was published in 1999 and made recommendations in relation to the way in which inquests were conducted. The report reflected the inquiry’s view that the overall inquest system was no longer fit for purpose. It made recommendations such as advance disclosure of evidence to parties who had leave to appear at the inquest, and legal aid to be provided to the bereaved families;
- Medical-related scandals led to calls for reform of the coronial system, culminating in the conviction of Dr Harold Shipman for the murder of 15 of his patients;
- A major review led by Tom Luce into the coronial system led to a hefty 300-plus-page report being published in 2003. That report said that inquests must undergo “radical change if they are to become fit for the purposes of a modern society”. That report drew attention to numerous deficiencies with the system at the time, including lack of sustained training of coroners, lack of legal and medical expertise, lack of resources and processes for working with other public bodies and the basis for coronial law being archaic, ancient structures.
As a result of events such as these, the Coroners Bill 2006 was created; it eventually find statutory footing as the Coroners and Justice Act 2009.
The 2009 Act made a number of changes to coronial law, which included:
- The introduction of the concept of an ‘investigation’ led by a coroner, of which the inquest represented the final part. This meant that inquests need not be opened every time a death was referred to the coroner and so lead to a reduced number of inquests;
- The appointment for the first time of a Chief Coroner;
- Changes to the circumstances in which a coroner must summon a jury;
- Appointments of Medical Examiners (this is only in force from 1 October 2023);
- Abolishing the office of Coroner of the Queen’s Household. Now any investigation or inquest passes to the coroner area in which the body is found.
The 2009 Act is the backbone to the inquest work which you, as coroners, practitioners, or interested persons, will be undertaking.
The 2009 Act does not solely relate to inquests. However, this is a book about inquests and so we shall focus only on those provisions which do govern inquests. Those sections have, by and large, been in force since 25 July 2013. There are various amendments which will come into force from 2024. If those amendments are relevant to a particular issue discussed in this book, they will be highlighted at the appropriate point.
The 2009 Act applies to all inquests which have taken place after 25 July 2013, regardless of when the death occurred. So for example, the most recent inquest into the deaths that occurred as a result of the Hillsborough Stadium tragedy in 1989 was governed by the 2009 Act, notwithstanding that the deaths the inquest investigated took place long before the Act’s commencement.
Section 43 of the 2009 Act provides the Lord Chancellor with the power to make regulations “at or in connection with investigations … (other than the practice and procedure at or in connection with inquests”. As a result, we have the Coroners (Investigations) Regulations 2013 (“the 2013 Investigation Regulations”).
The explanatory notes to the 2013 Investigation Regulations tell us that:
“These Regulations regulate the practice and procedure relating to investigations into deaths carried out under Part 1 of the Coroners and Justice Act 2009 (“the 2009 Act”).
Part 1 of the 2009 Act introduced a new regime for death investigations, which replaces the Coroners Act 1988 and the Coroners Rules 1984. Under the 2009 Act a coroner must conduct an investigation into violent or unnatural deaths, deaths where the cause is unknown and deaths which occur in custody or otherwise in state detention. In certain cases this investigation will include the coroner holding an inquest.
These Regulations form part of a package of new rules and regulations made under the 2009 Act which come into force at the same time as these Regulations.”
The Regulations make provision for matters relating to the investigation as a whole, such as the keeping of a register of reported deaths, providing information to the next of kin or personal representative of the deceased, the timing and arrangements in relation to post-mortem examination and transfer of investigations and the release of bodies for burial.
We will therefore find that, as this book focuses on the inquest process, we naturally do not refer to the 2013 Investigation Regulations as we may perhaps do with other sources of law and guidance.
Regulation 26 is of importance to the inquest process, when we consider in later chapters the duty of the coroner to complete an inquest within a specific expedient period of time. By virtue of Regulation 26, the coroner must notify the Chief Coroner of any investigation which has not been completed or discontinued within a year of that death being reported. The coroner must also provide explanation as to why this is the case.
Additionally, Part 7 of the 2013 Investigations Regulations is of importance to those of us focusing on the inquest process. Part 7 deals with action to prevent further deaths. This ties in with paragraph 7 of schedule 5 to the 2009 Act, which provides that the coroner has a duty to make a report for the prevention of deaths in similar circumstances when certain criteria are met. We will deal with this in further detail in Chapter 14.
The Coroners (Inquests) Rules 2013 (“the 2013 Inquests Rules”) came into force on the same day as the 2009 Act and replaced the Coroners Rules 1984. These Rules provide a set of procedural standards for the conduct of inquests and pre-inquest reviews.
The 2013 Inquests Rules make provision for matters such as the disclosure of documents, the management of the inquest hearing, admissibility of evidence, the summoning of juries and the record of the findings of the inquest.
One significant new development in the 2013 Inquests Rules was the provision of a statutory basis for pre-inquest review hearings. Before the 2013 Inquests Rules, pre-inquest reviews had taken place but they had not had any basis in the legislation: they had been conducted informally by coroners who recognised the need for greater case management in some of their cases.
Since the appointment of the first Chief Coroner through the 2009 Act, those of us practising in coronial law have had the benefit of a number of guidance documents and law sheets produced by the Chief Coroner.
They are all to be found online, on the Courts and Tribunals Judiciary website, and provide an invaluable set of resources for practitioners and coroners alike.
The guidance documents (of which there are currently 41) cover subjects ranging from the location of inquests and the appointment of coroners to the conduct of pre-inquest reviews, the conduct of inquests held entirely in writing and the framing of conclusions. They tend to be a few pages in length each and provide comprehensive but succinct guidance around their specific issues. Where there is guidance that is relevant to the particular subject that we are considering in this book, I include reference to that guidance at the appropriate points.
The law sheets (of which there are currently five) take similar form to the guidance documents but are focused on specific areas of law rather than practice or policy. For example, there is a lawsheet covering the topic of hearsay evidence, and a lawsheet covering the conclusion of unlawful killing. Again, where a law sheet exists which is relevant to the particular subject that we are considering in this book, I include reference to that sheet at the appropriate point.
Coroners do not act under the authority of the Chief Coroner, and they have their own independence in relation to their own inquest, so do not technically need to follow either the guidance or the law sheets. However, it is clear to see that an application to judicially review the decision of a coroner who has failed to follow the guidance of the Chief Coroner may have more weight than one which seeks to review the actions of a coroner who has paid heed to these documents.
There are a number of key people who feature in inquest proceedings. In brief, they are as follows.
Each inquest will have, at its head, the coroner. They will not only be steering the course of the inquest but will be making all major legal and procedural decisions – determining what evidence to call, questioning witnesses and ultimately reaching conclusions.
Within the inquest system as a whole, though, there are different types of coroners.
The Chief Coroner
At the head of the coronial system sits the Chief Coroner, whose appointment we have touched upon. The post of Chief Coroner was first created by Schedule 8 to the 2009 Act. The Chief Coroner is the national head of the coronial system.
The Lord Chief Justice appoints the Chief Coroner (paragraph 1(1) of Schedule 8 to the 2009 Act). The Lord Chief Justice must consult the Lord Chancellor about both the appointment and the duration of the term of office.
The appointee must be a High Court Judge or a Circuit Judge who is under the age of 70. On the date of writing (5 October 2023) the Chief Coroner is Thomas Teague KC.
The Chief Coroner has a number of powers and duties:
- To conduct inquests;
- To receive reports of all inquests and to make an annual report to the Lord Chief Justice;
- To control and take over the issue of reports on action to prevent future deaths;
- To have responsibility for the training of coroners;
- To maintain links with the Ministry of Justice Coroners Reform Team, the Judicial College and the Office of Judicial Complaints;
- To issue guidance dealing with issues that might arise in practice;
- To approve future coroner appointments;
- To keep a register of coroner investigations lasting more than twelve months, and to take steps to reduce unnecessary delays;
- To monitor investigations into deaths of service personnel overseas;
- To oversee transfers of cases between coroners;
- To provide an annual report on the coroner system to the Lord Chancellor, which is to be laid before Parliament;
- To collate, monitor and publish coroners’ reports to prevent future deaths;
- To direct coroners to conduct investigations in specific circumstances.
Deputy Chief Coroners
The Lord Chief Justice may appoint as many Deputy Chief Coroners as they consider appropriate. At the time of writing (5 October 2023) there are two Deputy Chief Coroners in post. The Lord Chief Justice must consult the Lord Chancellor about the appropriate numbers of Deputy Chief Coroners, and about the question of many should be judges and how many should be senior coroners / coroner for treasure.
The appointee must be a High Court Judge, a Circuit Judge, the coroner for treasure or a senior coroner. They must also be under 70 years of age. The term of office is determined between the Lord Chief Justice and the Lord Chancellor.
Senior Coroners, Assistant Coroners and Area Coroners
Before the 2009 Act, coroner areas were known as ‘coroner districts’. The 2009 Act amended the positions of coroners under the old coroner districts and added a new position of area coroner.
- Senior coroners under the 2009 Act are the same as coroners under the Coroners Act 1988. There is one senior coroner per area;
- Assistant coroners under the 2009 Act are the same as deputy coroners / assistant deputy coroners under the Coroners Act 1988. Each area should have a minimum of one assistant coroner;
- Area coroners are an entirely new post. They are qualified in the same way as assistant coroners.
These coroners are appointed by local authorities with the agreement of the Lord Chief Justice and the Chief Coroner.
The Chief Coroner has created a specialist cadre of coroners in England and Wales. These are coroners who are specially trained and conduct investigations and inquests into service and military deaths. They deal with deaths overseas and those that take place in England and Wales.
Unlike civil or criminal proceedings, which may be the usual stomping ground of many practitioners who are new to inquests, an inquest is not a strict adversarial process. It follows that there are no ‘parties’ to the inquest, as there are no ‘sides’.
However, there are ‘interested persons’ – they are people recognised by the court as having a particular interest in the proceedings. The concept of ‘interested persons’ in the 2009 Act replaces the old concept of ‘properly interested persons’ that was previously in place under the Coroners Rules 1984. Other than the change in name, there seems to be little significant difference between them.
Who can be an interested person?
The coroner leading the inquest designates which people or organisations can be given ‘interested person’ status, by reference to the statute.
Section 47 of the 2009 Act sets out the categories of people who are to be considered ‘interested persons’:
“47 “Interested person”
(1) This section applies for the purposes of this Part.
(2) “Interested person” , in relation to a deceased person or an investigation or inquest under this Part into a person’s death, means—
(a) a spouse, civil partner, partner, parent, child, brother, sister, grandparent, grandchild, child of a brother or sister, stepfather, stepmother, half-brother or half-sister;
(b) a personal representative of the deceased;
(c) a medical examiner exercising functions in relation to the death of the deceased;
(d) a beneficiary under a policy of insurance issued on the life of the deceased;
(e) the insurer who issued such a policy of insurance;
(f) a person who may by any act or omission have caused or contributed to the death of the deceased, or whose employee or agent may have done so;
(g) in a case where the death may have been caused by—
(i) an injury received in the course of an employment, or
(ii) a disease prescribed under section 108 of the Social Security Contributions and Benefits Act 1992 (c. 4) (benefit in respect of prescribed industrial diseases, etc),
a representative of a trade union of which the deceased was a member at the time of death;
(h) a person appointed by, or representative of, an enforcing authority;
(i) where subsection (3) applies, a chief constable;
(j) where subsection (4) applies, a Provost Marshal [ of a service police force or of the tri-service serious crime unit]1 ;
(k) where subsection (5) applies, the [Director General of the Independent Office for Police Conduct]2 ;
(ka) where subsection (5A) applies, the Service Police Complaints Commissioner;
(l) a person appointed by a Government department to attend [ or follow]4 an inquest into the death or to assist in, or provide evidence for the purposes of, an investigation into the death under this Part;
(m) any other person who the senior coroner thinks has a sufficient interest.”
It is worth noting that, despite the long list of relatively specific categories, the coroner retains discretion to appoint as an interested person anyone who does not otherwise fit into the section 47 of the 2009 Act. This is provided for by the ‘sweep-up’ provision in section 47(2)(m) of the 2009 Act.
What rights does an interested person have?
Where a person is designated as an interested person their rights include:
- To be notified of the date, time and place of the inquest hearing (Coroners (Inquests) Rules 2013, r.9(2)) and to attend the same;
- Subject to any restrictions on disclosure arising under r.15 of the Coroners (Inquests) Rules 2013, to be provided with a document or a copy of that document (Coroners (Inquests) Rules 2013, r.13(1));
- To examine any witness either in person or through their representative (Coroners (Inquests) Rules 2013, r.19(1)); and
- To make submissions to the coroner on matters such as conclusions.
R v Greater London (South District) Coroner ex parte Driscoll
(1995) 159 JP 45:
The sister of the deceased sought to judicially review the coroner’s decision that she was not a properly interested person under the Coroners Rules 1984. In allowing the application, the Court held that close blood relations who were in contact with the deceased before he died are interested persons for the purposes of the Rules. The coroner had been wrong to take into account the acrimonious relationship between the applicant and the deceased’s wife.
Some key points from the case are:
- The word ‘interested’ should not be given a narrow or technical meaning: it is not confined to a proprietary right or financial interest in the estate of the deceased;
- An applicant for interested person status must show that they have “more than idle curiosity. The mere fact of being a witness will rarely be enough. What must be shown is that the person has a genuine desire to participate more than by the mere giving of relevant evidence in the determination of how, when and where the deceased came by his death.” (per Kennedy LJ);
- The other categories of person in the statutory sub-paragraphs are to be used as a guide to the type of person that may qualify under the ‘sweep-up’ category;
- When deciding whether to grant the status of interested person, a coroner is not entitled to take into account any (no matter how understandable) desire to avoid unpleasantness or ill-feeling at the inquest. For example, it is irrelevant that members of the deceased’s family may not wish a particular person to be recognised as an interested person;
- It is not helpful to look to the law on standing in Judicial Review proceedings as analogous to interested person status;
- Family relations and non-consanguineous relationships not mentioned explicitly in the legislation can be recognised as interested persons under the ‘sweep-up’ category.
Coroner’s inquests into the London bombings of 7 July 2005 – Decision following pre-inquest hearing from 26 to 30 April 2010
The inquests into the deaths of 52 people killed in terrorist attacks in London was conducted by Hallet LJ. Over the course of the proceedings, she delivered various rulings which have been of assistance to practitioners and coroners since.
At the pre-inquest hearing from 26 to 30 April 2010, Hallet LJ considered various individual applications for interested person status (at that time, ‘properly interested person’). Out of her decisions, it seems the following were important factors in determining that a certain person or category of persons should be interested persons (see paragraphs 122 to 136):
- Played a significant role in the events;
- A genuine desire to participate and assist the process;
- Able to offer specialist help to the investigation.
In that decision, the coroner found that the survivors did not meet the criteria for being properly interested persons. At paragraph 135 to 136:
“135. However, I need not dwell upon my concerns and I return to the question in hand: should I exercise my discretion in favour of designating the survivors under rule 20? I needed no reminding of the extent of the suffering of those who survived the bombs. The Scene Reports make graphic and extraordinarily distressing reading even for those of us used to horrific criminal acts. I needed no persuading that many survivors will have a valuable role to play in the resumed inquests. However, at times I confess Mr O’Connor’s submissions, with great respect to him, seemed to me to be more about providing a mechanism for the survivors to obtain legal representation than the legitimate scope of designated person status under rule 20. These are inquests under a particular statutory regime. They are not a public inquiry under the Inquiries Act 2005 or otherwise. I have an independent legal team available to the survivors and to others to ensure issues they may wish to pursue are brought to my attention and, if I think it appropriate, canvassed in evidence. To my mind it does not require separate representation and therefore separate public funding to ensure their interests are properly protected. I intend to make sure survivors feel they are a proper part of the process. To that end, I have already authorised the release of the Scene Reports to those survivors who have signed the confidentiality undertaking. Survivors may attend the proceedings whenever they wish. Some will be called to give evidence. I shall encourage them to use the services of the Inquest Team and to ensure that we pursue all legitimate lines of inquiry and ask all relevant questions. I will read and hear submissions from them if they wish to submit them. I will ensure the process is as open as possible. A transcript of the public proceedings will be published each day on the website thereby enabling the survivors to follow them in detail. I will ensure that all survivors are treated with care and sensitivity.
- However, as sympathetic as I feel towards them, I must bear very much in mind the primary functions of an inquest which are to inquire into the four statutory questions about the deaths and I must bear in mind the views of some of the bereaved families. I take Mr O’Connor’s point that it was not clear exactly how many bereaved families are united in opposing the application to designate the nineteen survivors as interested parties, but in my judgment, there were enough. There was clear anxiety on the part of a significant number. If Mr O’Connor or any of the survivors in person had been able to identify for me issues upon which they have a unique perspective, which could only properly be reflected by their being able to ask questions, I might have decided differently. They were not. In those circumstances, I can see no proper legal basis for designating the survivors as interested persons in addition to all the others designated. There will be numerous parties represented and asking questions at the resumed inquests and there may be unrepresented parties wishing to ask questions. I will have to control them all (within reason) if I am to keep to the strict timetable I wish to set. I want the bereaved families and the survivors to have as many answers as possible and preferably by the end of the year. Adding to the list of those entitled to ask questions I fear will not assist that process.”
Allman v HM Coroner for West Sussex (2012) EWHC 534 (Admin)
This case related to an application for interested person status by a person who, knowing the deceased in life, had made a promise to them to ensure that the death was fully and properly investigated. In upholding the coroner’s refusal to accord this person interested person status, the Court stated (at paragraph 25):
“25. It follows that the Deputy Assistant Coroner was well within her rights to refuse Mr Allman properly interested party status since his wish for that status was essentially to fulfil his promise to the deceased that he would ensure that the circumstances of his death would be fully and properly investigated by the police and the inquest process if he met his death in what might loosely be described as suspicious circumstances. Since there was no such evidence, there was no basis for his being accorded properly interested party status. Moreover, it is clear that all the relevant evidence that Mr Allman wished to place before the jury was in fact placed before the jury since it was relevant to their consideration of the deceased’s state of mind. Mr Allman’s wider evidence about electromagnetic weaponry in general and its propensities to kill and of its use by security forces in covert assaults on persons those forces wish to destroy or whose political protests they wish to neutralise was not relevant for the jury in this case to consider and, in any event, was prohibited from being adduced at this inquest by virtue of Rule 36 which precludes consideration of opinions and hypothetical situations which have no evidential link to the particular death being considered.”
Platts v HM Coroner for South Yorkshire (East District) and Chief Constable of South Yorkshire Police (2008) EWHC 2502 (Admin)
The former girlfriend of the deceased was held to be a properly interested person under the Coroners Rules 1984. One of the reasons for this was the fact that her interest was genuine and directed to a proper motive, namely questioning whether the system had let the deceased down, notwithstanding that she had not been in a relationship with the deceased when he passed away.
In addition, the Court noted that the fact that a person may wish to bring a civil claim for damages as a result of the death of the deceased neither qualifies nor disqualifies them from interested person status.
Re Northern Ireland Human Rights Commission (2002) UKHL 25
This case is authority for the proposition that a public interest organisation may be recognised as an interested person in an appropriate case, even if they have no connection with or specific knowledge of the deceased. The Court held that relevant considerations include whether the group will assist the coroner to perform the role in which he or she is engaged, such as by having expertise in a relevant legal or factual area (paragraph 32).
R (Southall Black Sisters) v HM Coroner for West Yorkshire (2002) EWHC 1914 (Admin)
This was a case where the group (Southall Black Sisters) sought to rely on the ruling in Re Northern Ireland, supra, to argue it should have interested person status. However, in this case the Court declined to overturn the decision of the coroner. At paragraph 53:
“53. … It was a matter for the coroner to form an opinion whether the claimant was a properly interested person in relation to the two inquests before him. The fact that the claimant had virtually no connection with the family of the two deceased was a relevant consideration. The fact that the claimant had no direct knowledge of the circumstances in which the two deceased had died was a relevant factor, although not (in isolation) a conclusive one. It seems to me that the coroner in this case formed a perfectly rational decision which is not amenable to challenge by judicial review.”
R v Coroner of the Queen’s Household ex p Al-Fayed (2001) 58 BMLR 205
Mr Al-Fayed sought interested person status in the inquest into the death of Diana, Princess of Wales, who had died in the same car crash which killed Mr Al-Fayed’s son. In considering the claim, the Divisional Court expressed approval for the coroner’s proposition that Rule 20(2)(h) of the 1984 Rules (the equivalent provision to section 47(2)(m) in CAJA 2009) could be used to prevent injustice in relation to those who were not caught in the preceding provisions. In this case, it was held that such injustice would not occur because the separate inquest into the death of the applicant’s son, Dodi Fayed, would have access to all the material available at the planned subsequent inquest into the death of Diana, Princess of Wales.
 Death Certification and investigation in England, Wales and Northern Ireland. The report of a Fundamental Review 2003, chaired by Tom Luce, at paragraph 3; available at https://webarchive.nationalarchives.gov.uk/ukgwa/20131205105739/http://www.
archive2.official-documents.co.uk/document/cm58/5831/5831.pdf, last accessed on 5 October 2023
 Section 43(1)(a) of the 2009 Act
 Para 1 of Explanatory Note to the 2013 Investigation Regulations
 https://www.judiciary.uk/courts-and-tribunals/coroners-courts/coroners-legislation-guidance-and-advice/coroners-guidance/, last accessed 5 October 2023.