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.

Ths blog is and will always remain free to readers….but…

If you ever have found the blog posts we provide  interesting or useful we wondered if you might consider, just quietly, showing your gratitude for these free posts by (virtually) pulling a tenner out your back pocket and sponsoring the Chief Coroner, HHJ Alexia Durran,  who completed the london marathon in  5 hrs, 27mins and 36 secs  on 27th April – raising £19,300 for the Coroners Court Support Service.

Anyone who works in and around Coroners Courts will have met the excellent volunteers from the Coroners Court Support Service and come to appreciate the valuable work they do,  helping all those who attend at a Coroner’s Inquest.

Many people attend inquests without anyone with them who is familiar with courts or the inquest process.  Understandably they feel anxious about attending a court hearing, and perhaps particularly so where it involves listening to or talking about how someone died.

The Coroners Court Support Service is an independent voluntary organisation that provides trained volunteers to provide emotional and practical help to bereaved families, witness and others attending a coroner’s inquest. 

As a charity CCSS do not receive any central funding but rely upon grants and donations to carry out their esential work. 

CCSS’ vision is, and always has been, to set up the Service in all of the Coroners’ Courts within England and Wales to ensure bereaved families, witnesses and others have access to the Service wherever they attend an Inquest. They can not do so without our help.

It would be excellent to get HHJ Durran’s final total up to £20k and so there is still time for you to sponsor the Chief Coroner here…..

https://2026tcslondonmarathon.enthuse.com/pf/thechiefcoroner

If everyone who reads this blog regularly just handed over £10 – the price of 3 cups of coffee – then the Chief Coroner would smash her target.

Thank-you so much for any support you might offer to the CCSS and the encouragement you will give to HHJ Durran for making her way so quickly round the 27 mile course (and doing it without those clever shoes that Sabastian Sawe had)

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.

R (Olabode) v HM Area Coroner for Manchester City & Manchester University NHSF Trust (2026) EWHC 810,  2 April 2026, judgment here.

Coroners and inquest practitioners seeing this 31 page judgment land on a Maundy Thursday need not worry that they might now have a lot of reading to interrupt their Easter break.  Despite the lengthy, detailed and erudite judgment of Mrs Justice Hill this case does not develop coronial law one iota – it is a case uniquely confined to its facts.

But gosh! what an incredibly complex set of facts these were.   Indeed Hill J is rather playing down the intricate detail she had to grapple with when she opens her judgment saying that “this claim has involved the consideration of incredibly detailed expert evidence”.  There were eight experts from seven specialist medical disciplines who provided their views to the Coroner on cause of death and causation during the inquest under challenge.  Inevitably they did not all agree with each other: indeed they agreed and disagreed in different ways on different things. The medical evidence was so convoluted that those present in the Admin Court in Manchester last week report that a far more apt reference was made at the hearing to “needing a towel on the head” before one might even begin to understand it.

As anyone who was not born this century ought to know, a towel is of course about the most massively useful thing an interstellar hitchhiker can have.[1]  But happily you won’t need your own towel here, as Hill J has done all the hard work for you. Just jump to paragraph 113 to find the single learning point for coroners and inquest practitioners that comes out of this case, which is:

When inquest evidence is this complicated, and even if Art 2 is not engaged, it’s a jolly good idea for counsel to help out the coroner by proposing a list of key issues that the coroner should consider and cover off when coming to their findings of fact.

And then perhaps also join your blogger in celebrating the forensic analytical skills of both the Area Coroner for Manchester City and Hill J[2] next towel day, on 25 May (assuming there is no appeal, in which case three more towels will probably be needed).