Re Jordan's Applications for JR - Delay & Damages [2015] NICA 66

From the inquest that just keeps on giving a further judgment of the Northern Ireland Court of Appeal (‘NICA’) has been published concerning the award of damages under the Human Rights Act as compensation for the continued delays in bringing to a conclusion the (still unfinished) inquest into the death of Pearse Jordan who was shot by an RUC officer on the Falls Road in 1992.

“The investigation into the death of a close relative, impacts on the next of kin at a fundamental level of human dignity. It is obvious that if unlawful delays occur in an investigation into the death of a close relative that this will cause feelings of frustration, distress and anxiety to the next of kin”. Stephens J

A huge number of legal decisions, including more than 25 Judicial Review applications have already arisen from the procedural inadequacies in investigating this death. In 2001 an award of £10,000 as compensation for the delay up to that point was made by the European Court in Strasbourg, which called into question whether the Northern Irish inquest system was, at the relevant time, structurally capable of providing for both speed and effective access for the deceased’s family. 

R (Fullick) v HM Coroner for Inner London North [2015] EWHC 3522 (Admin) 3 Dec 15

Susan Jones died after falling ill at a police station after she had attended the station voluntarily as a witness.  An alcoholic, homeless and on methadone, she was vulnerable and police statements made it clear that the officers felt they owed her a duty of care: as the Chief Coroner put it, “at the very least she needed looking after”. Having given an interview, Susan was waiting for a specialist team to attend.  While waiting she placed her head on the table and appeared to fall asleep, being heard snoring. She was left for some time, checked once, but not roused. Nearly two hours later, officers realised she was not breathing. An ambulance was called and CPR commenced, but she died in hospital just over a week later.

The Coroner’s initial decision not to hold her inquest with a jury was overturned by the High Court, comprising the Chief Coroner and McCombe LJ.

‘Reason to suspect’ is a low and objective threshold: suspect’ means suspicion: ‘a state of conjecture or surmise.’

Jones v HM Coroner for Gwent and others [2015] EWHC 3178 (Admin) 5 Nov.15

The Divisional Court this week made clear the limits of s.13 Coroners Act 1988 when seeking to overturn and inquest.  Where Judicial Review is the correct vehicle to challenge the decision of a Coroner then the failure to bring such a claim in good time should not be circumvented by an application for a fresh inquest under s.13.

Elberte v Latvia ECtHR App.No. 61243/08 13 April 2015

Next month the Human Transplantation (Wales) Act 2013 comes in to force. Described as the most significant piece of legislation passed by the Welsh Assembly, it will make Wales the first UK country to introduce a ‘soft opt-out’ system for organ and tissue donation. From 1 December 2015 a deemed consent system will operate for organ donation where the presumption will be that people aged 18 or over, who have been resident in Wales for over 12 months, want to donate their organs at their death, unless they have specifically objected.  

This Act has laudable objectives and is anticipated to save countless lives through a 25% rise in the availability of organs for transplant.  

However, those who favour an opt-in system warn of the excesses that can happen if state control and oversight of such a system is lax. Such risks were shown in stark detail in a recent European Court of Human Rights decision involving Latvia, where shocking abuse of a ‘presumed consent’ system was revealed. 

Smith v HM Coroner for Cornwall (2015) 22/10/2015

The important role a coroner’s inquest has to play in elucidating factors relevant to the death in a way that might then allow for the greater protection of the wider public is exemplified by this recent decision of the Divisional Court.  Inquests into two deaths from carbon monoxide poisoning were overturned where full information regarding the knowledge and correction of a design fault in the gas cooker thought to be responsible had neither been available nor explored.

Serjeants’ Inn Chambers recently hosted an evening with Sir Robert Francis QC to discuss and reflect upon the impact of the Duty of Candour, as recommended in the 2013 Francis Report, upon practice in a variety of healthcare areas. Cecily White and Paul Spencer considered the impact in the Coronial jurisdiction of the rather snappily named “Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014”   (ie the Duty of Candour regulations).  Their paper, reproduced here, is summarised below.

Wilson v HM Coroner for Birmingham and Solihull [2015] EWHC 2561 (Admin)

“Fairness in an inquest must be fashioned in an environment where there are no pleadings and in which those given leave to appear as interested persons do not have a case to put. The evidence at inquests often takes an unexpected turn and calls for a degree of flexibility in the procedure to be followed as a consequence. The rules of evidence applied in criminal and civil proceedings do not apply. Questions of fairness to those involved in inquest proceedings must be judged against all these essential features and also in the context that the statutory scheme prohibits a finding of criminal liability on the part of a named person, or of civil liability” 

Burnett LJ

Mr. Wilson, a consultant cardiothoracic surgeon, applied for judicial review of part of the coroner’s conclusions in relation to the deaths of three of his patients having undergone cardiac surgery at his hands. 

Thompson v HM Assistant Coroner for Durham [2015] EWHC 1781 (Admin)

Kristian Thompson was 19 years old when he died.   He was a detained patient in a hospital secure unit under s.3 Mental Health Act. On the day of his death he had suffered an episode of incontinence and went to shower. He was found in the shower, collapsed on the floor with the shower running. He did not recover.

At the inquest in November 2012 the assistant coroner returned an open verdict, recording the medical cause of death as "unascertained". The pathologist and consultant neuro-pathologist involved in the post-mortem and the consultant physician who had been involved in Kristian’s treatment post-collapse considered two possible causes of death (sudden and unexpected death in epilepsy (‘SUDEP’) and sudden adult death syndrome (‘SADS’).  In the absence of an ante-mortem diagnosis of epilepsy the doctors were unable to come to any probable conclusion.  However, the pathologist stated that he would alter his opinion on the cause of death if an expert clinician could diagnose epilepsy at any time.

There had been insufficiency of inquiry such that it was necessary and desirable in the interests of justice to hold a fresh inquest

On 20 August 2015 the Lord Chancellor published revised guidance on civil legal aid funding in inquest cases. It takes into account the conclusions of the Court of Appeal in the case of  Letts v The Lord Chancellor [2015] Inquest Law Reports 15,  and now recognises that there are some categories of case in which the mere fact of death gives rise to a possibility of State responsibility and this suffices to trigger the Article 2 procedural duty to conduct an independent investigation.   

The previous guidance had suggested that an arguable breach of a substantive duty had to be identifiable to engage the need for an Art 2 inquest.   It is now made clear that there are certain categories of death where the automatic duty arises whether or not the evidence in the case discloses an arguable breach of any of the substantive obligations.

Senior Coroner for Cumbria v Ian Smith [2015] EWHC 2465 (Admin)

Poppi Worthington, was only 13 months old when she died in hospital in December 2012 having apparently sustained fractures to her leg and other injuries.   Yet despite there clearly being reason to suspect that this was a violent or unnatural death, and an inquest already having been held, none of the facts surrounding her death have as yet been made public.    Poppi’s inquest in October 2014 took only seven minutes to complete; the Coroner returned an open conclusion and found that her cause of death was ‘unascertained’.   It is hardly surprising then that the High Court has now overturned that first inquest and determined that a fresh inquest should be held.

“The Coroner did not give any information about the circumstances leading to the girl’s death. The inquest did not address questions about her welfare, how she was discovered, whether any attempts were made to revive her and whether any public agencies were at fault.” 


This case re-emphasizes the duty of coroners to hold their inquests fully in public no matter how difficult the surrounding circumstances. Moreover, that this case had to be brought by the present Senior Coroner against the previous Senior Coroner brings into question whether there should be some simpler mechanism than requiring a Senior Coroner to, firstly, seek a fiat of the Attorney General and, secondly, make a High Court application under s.13 Coroner’s Act 1988 when he or she seeks to put right obvious shortcomings and hold a fresh inquest.