Tindall and another v Chief Constable of Thames Valley Police [2024] UKSC 33, (judgment here)

It is not coronial law under the microscope here, but rather a decision from the Supreme Court at the end of last year in a police civil action.  Nevertheless it provides helpful insight into the potential responsibility of police forces in their deployment to incidents that coroners and inquest practitioners will need to bear in mind should  a neglect or gross negligence manslaughter/unlawful killing conclusion be under consideration.

The Supreme Court was concerned with the test for the imposition of a duty of care in a civil claim for compensation.  The Court considered the elusive dividing line between ‘failing to protect a person from harm’ (where no duty of care arises) and ‘making matters worse’ (when a duty does bite). The Court acknowledged that drawing this distinction is “not always straightforward” [1] – which is perhaps something of an under-statement!

Thompson’s Application for Judicial Review [2025] NICA 25 (Judgment 13 May 2025, here)

Whilst the context of this case concerns the grant of anonymity, it has much wider relevance as it addresses the legal issue of identifying the precise point at which a coroner will become functus officio, such that they can no longer take any steps related to an inquest.

That cut off point is important to know, given the power of a coroner to change previous procedural decisions generally only pertains whilst the inquest is still current[1] and so any review or amendment of an earlier coronial decision must be completed before the inquest is closed.

The specific question that arose in this case was whether a review of a grant of anonymity might be conducted after an inquest had concluded.   Spoiler alert: No it can’t. So both counsel and the coroner should be alert to the need to deal with this issue before the inquest ends.

Morrow v HM Assistant Coroner for Merseyside [2025] EWHC 935 (Admin) 15 April 2025 judgment here

What the bereaved hope might be investigated at an inquest and what the inquest actually explores are often very different things.    In this recent case the Assistant Coroner’s decision to draw a very tight investigatory scope was upheld by the Divisional Court.  There is no new law here.  Coroners have a wide discretion regarding scope and that discretion was properly exercised. The Coroner was entitled to have heard only limited evidence related to events very close to the time of death.

However there is still a lot to be learned from this case regarding how to avoid later conflict by bearing in mind the difficult position of an unrepresented bereaved family; seeking their views appropriately; managing their expectations by ensuring they fully understand the process;  providing them full explanations of why an inquest’s scope might be narrowly drawn along with the reasons for relevant coronial decisions. 

R (Robinson) v. HM Assistant Coroner Blackpool & Fylde [2025] EWHC 781 (Admin), 3 April 2025 (judgment here)

The ever the developing jurisprudence of Article 2 means that the categories of cases that can engage Art.2 obligations is not closed. However, in this recent decision Kerr J has firmly slammed the door in the face of Claimant who was proposing an extension of Art.2 into cases of misadventure occurring in police officers’ presence, saying that he “did not see any good reason to extend the existing categories of case in which article 2 applies automatically.”

The automatic Art.2 categories are considered automatic because the state will always need to explain how a death in specific circumstances came about: a paradigm example being where a suicide occurs in custody. But as the judge here recognised, it is not the mere fact of being in state custody that triggers the obligation. Cases of misadventure, even if occurring in police custody, are not apt to attract the automatic application of Art.2, because the misadventure may be unpredictable; the state agents may bear no blame for it; and it may require urgent medical attention beyond their expertise.

O’Brien v HM Assistant Coroner for Sefton, Knowsley and St Helens [2025] EWHC 362 (Admin) (heard in September 2024) the recently un-embargoed judgment is here

The Court of Appeal made the point resoundingly clear in Morahan[1] that “an inquest remains an inquisitorial and relatively summary process”.   As this latest case illustrates a Coroner may well be under a duty to seek out and record as many facts as the public interest requires, but this will not mean that the scope of an inquest must always be as wide as the Interested Persons might demand.   Rather, as the Master of the Rolls said in Dallaglio:

“It is for the coroner conducting an inquest to decide, on the facts of a given case at what point the chain of causation becomes too remote to form a proper part of his investigation. That question, potentially a very difficult question, is for him.”

The touchstone for the Scope of any inquest will be what was called in this case ‘Coronial Causation’, a term flowing from the decision in Tainton where the President had noted the difference between the threshold for causation of death and the standard of proof required to prove causation of death at an inquest.

The conduct or event must make an actual and material (that is more than minimal) contribution to the death. Depriving the deceased of an increased chance of life, or making their death more probable than it would otherwise have been will not be enough to satisfy the causation threshold for a coroner.