HM Senior Coroner for Cornwall And the Scilly Isles [2024] EWHC 2673 (Admin). 22 October 2024.  Judgment here

Where a Coroner has conducted an inquest and, through no fault of their own, done so on the basis of an incomplete picture of the circumstances surrounding the death,  both the interests of the bereaved and the public interest will make a fresh investigation and inquest both necessary and desirable in the interests of justice.

In this recent example of a Senior Coroner seeking to overturn their own inquest after new information has come to light, the High Court efficiently heard together and granted two applications brought under s.13 Coroners Act 1988.  In each case, substandard surgical care had first been implicated in the death some years after the original inquests had concluded

HM Senior Coroner Sarah Ormond-Walshe v Sherren [2024] EWHC 2332. Judgment (here) 30 July 2024

Language matters, particularly in public life.  It is now well accepted that no coroner or inquest lawyer should ever say (or invite a jury to find) that someone has ‘committed suicide’.   That archaic term connoting criminal conduct not only carries inappropriate pejorative connotations but, since Maughan clarified the standard of proof for suicide, it is also misleading to use a term usually associated with criminal findings.

Two High Court judges have now also made it clear why using the term ‘suicide note‘ should be strenuously avoided.

Senior Coroner for Northamptonshire v Lovell and Teague [2024] EWHC 2331 (Admin) 30 July 2024. Judgment here

It is rare for the High Court to refuse an application by a Senior Coroner to overturn their own inquest. However in this case the judges were not persuaded that it was either necessary or desirable to make the order that the Coroner sought.

The case centred around two deaths in the same fatal road crash.   What the Coroner wished to correct was a single aspect of the determination she had arrived at in the car passenger’s inquest (relating to the amount of alcohol the driver had consumed), which the car driver’s subsequent inquest had revealed to be incorrect.

However the Court did not agree that a fresh investigation and inquest was necessary:  the consumption of alcohol had not been stated to be causative of the passenger’s death and in any event the existence of the High Court judgment alongside the driver’s Record of Inquest meant that the public record taken as a whole now clarified the true position.

It was also not desirable to hold a fresh inquest given the wishes of the parents of the deceased who did not relish the distress of the thought of a second inquest re-opening painful matters for them, and where holding yet another inquest also opened up the risk, however small, of yet further inconsistent findings relating to a single accident which had killed two young people.

University Hospitals Bristol and Weston NHS Foundation Trust v The Mother of G [2024] EWHC 1288 (Fam)

Generally coroners will not be involved in a case until the fact of death is clear (advance consultation in organ donation cases perhaps being the notable exception). But for those rare times when there may be a dispute about whether a death has or has not yet occurred, so as to trigger the coroner’s jurisdiction, Mr Justice Peel has provided helpful guidance on this area of law and how an application for a declaration of death might be made.