R (O’Brien) v HM Assistant Coroner for Sefton, Knowsley and St Helens [2026] EWCA Civ 605 (19 May 2026) Costs judgment here.

As readers of this blog should already know ‘neutral means neutral’ if you are a Coroner responding to a Judicial Review claim (and if you didn’t know that, see our 2018 blog following the High Court decision in Worthington: here).  Of course in that case the Coroner had ‘succeeded’ in defending the claim, so any judicial comment regarding the payment of costs (even though made by a three judge Divisional Court which included the Chief Coroner) was pure obiter.  Nevertheless the entire Bench had been quite keen to stress that it is really not a very good look for a Coroner to say one thing yet do another.

The Divisional Court in Worthington had sent out a strong message to Coroners that there should be no sleight of hand, saying that: “We do not condone any practice of Coroners … insofar as it exists, of stating that they are taking a neutral stance … but then making submissions that are clearly not neutral but partisan”.  What was made clear in Worthington was that when determining liability for costs what is relevant is the stance the Coroner has actually taken and not the stance the Coroner says they have taken.

If any Coroner might have since thought the High Court didn’t really mean it, then Lord Justice Edis in the Court of Appeal has just taken up a VERY LARGE PINK HIGHLIGHTER to put the matter beyond doubt.

Chief Coroners Guidance for Coroners on the Bench – Updated 10 May 2026 here

A series of updates to the Chief Coroners ‘Bench Book’ have just been published. As the Chief Coroner made clear at its initial publication her Guidance for Coroners on the Bench is intended to be an internet based resource.  Printing a hard copy may not only unnecessarily kill trees but also risks you overlooking the various updates to the ‘Bench Book’ as they come on stream.

One of these updates now deals with the rare (but not wholly exceptional) circumstances of a dispute arising between family members as to whom a body should be released, or how the body should be respectfully disposed of. The updated Guidance proposes that the coroner should first identify if the deceased has made a will and who is the executor of the will. Where there is an executor, the body should be released to the executor to make the appropriate arrangements in accordance with the deceased’s wishes.

Coroners may on occasion need to make a decsion between family factions and the need to avoid delay should be the impetus for coroners doing so. Expediting the funeral having been identified as “the most important consideration” in Hartshorne v Gardner,^[1] indeed the key theme emanating from all the relevant authorities focuses on avoiding delay and ensuring the dignified and decent disposal of the body.

R (O’Brien) v HM Assistant Coroner for Sefton, Knowsley and St Helens [2026] EWCA Civ 499 (22 April 2026) here.

The Court of Appeal has handed down some useful guidance on how to approach the thorny issue of causation in deaths where domestic violence has been a factor and there had been previous contact with police.  At first instance the High Court had held that it would have been  speculative of the Coroner to consider what might have been the position had the perpetrator been arrested before the death: the Court of Appeal did not agree.

In this 17 page judgement Lord Justice Edis guides us all on how to navigate the various “what ifs” associated with the potentially uncertain terrain of the criminal justice process.  Readers may well now be rushing to the latest editions of various criminal sentencing guidelines to navigate this new terrain.

R(AH) and R(IS) v Secretary of State for the Home Department [2025] EWHC 3269 Admin,  judgment (15 December 2025) here

Article 2 ECHR encompasses a ‘systems duty’ which requires public bodies to protect all citizens by having both appropriate state regulation and functional procedures and policies in place to offer protection where life might otherwise be at risk. Spotting flaws in a system is an important exercise for inquest lawyers, as when death arises from an arguable breach of the systems duty this will trigger a ‘Middleton’ ‘Article 2 Inquest’.

However it can sometimes be tricky to spot whether what one is looking at is an error by an individual in how they have operated the system in question (which is not a systems breach), rather than a flawed or wholly absent system (which is).  Someone operating within an adequate well-functioning system and making a mistake (even a very bad one) is insufficient for a systems failure. A single cog failing to turn within an otherwise functional and well well-oiled machine will not reach the standard necessary to show a breach.

However, this judgment by Mrs. Justice Jefford might make you think again about when repeated individual failings might reveal more than someone simply having a bad day at work, but actually reveal that the system although capable of working effectively was not being implemented and so was not working effectively. Where the failure is not in the system’s design, but in ensuring the implementation of the system an ECHR systems breach may still be made out.