HM Senior Coroner for South London v Alexei [2025] EWHC 2768 (Admin), 7 October 2025, judgment here

The question of which evidence to call at an inquest is a matter for the coroner alone. The coroner should call sufficient evidence and conduct a sufficient inquiry to answer the statutory questions. However, the Courts have repeatedly emphasised the wide area of judgment that a coroner enjoys in deciding who to call to give evidence.[1] It is a matter of coronial discretion whether their investigation has uncovered sufficient evidence on a key point to allow for an adequate inquest to then follow.  ‘Sufficient’ is not a particularly high standard, an adequate investigation will be good enough.  The decision regarding whether further evidence should be sought will often be made bearing in mind a number of factors, including: (i) the rule 8 requirement to complete an inquest within six months; and (ii) how likely it is that any additional evidence that might be obtained will contradict the evidence that is already available.

However where a coroner goes ahead on the basis of only a provisional or preliminary  medical expert report there is always a risk that the expert’s final opinion might differ.  Unfortunately for the coroner holding this inquest, that is precisely what occurred.

Commencing 6 November 2025

The Centre for Contemporary Coronial Law at the University of Greater Manchester  is pleased to announce that the highly successful Coronial Law short course will be offered again, starting on Thursday, 6th November 2025.

Designed for practitioners working in, with, or aspiring to join the coronial service, the course blends clear legal foundations with practical, court-facing skills to build confidence in real investigations and inquests. It is ideal for coroner’s officers, hospital coronial liaison staff, legal representatives, those seeking coronial roles (including newly appointed coroners), and others involved in the inquest process.

Course Schedule:

• 6th November 2025
  Lecture 1 – Coroners
  Professor Alan Walsh (Retired HM Area Coroner, Manchester West)
• 20th November 2025
  Lecture 2 – Investigations
  Professor Christopher Dorries OBE (Retired HM Senior Coroner, South Yorkshire West)
• 4th December 2025
  Seminar/Case Studies
  Professor Christopher Dorries OBE
• 18th December 2025
  Lecture 3 – Inquests (Part I)
  Professor Alan Walsh
• 8th January 2026
  Lecture 4 – Inquests (Part II)
  Professor Alan Walsh
• 22nd January 2026
  Lecture 5 – Article 2
  Timothy Brennand
  HM Senior Coroner, Manchester West
• 5th February 2026
  Mock Inquest and Celebration
  Professor Christopher Dorries OBE & Professor Alan Walsh

Course Details:

• All sessions will be conducted via MS Teams from 18:00 to 20:30.
• The cost per session is £50, or £300 for the complete series.
• To book your place:

  Book the Coronial Law Short Course

Contact Information:

For more details, please contact Dr Alicia Danielsson.

Email: CoronialLaw@greatermanchester.ac.uk

R (Ferguson) v  HM Assistant Coroner for Sefton, Knowsley & St Helens and the Chief Constable of Merseyside Police [2025] EWHC 1901 (Admin) 23 July 2025 –  judgment here

Q1: What strength of evidence will make it arguable that an article 2 duty has arisen and/or make it arguable that a duty has been breached, so as to trigger an Art 2 compliant inquest?

Q2: For a mandatory jury to be required need there be an inappropriate act or omission by police, or is their mere involvement enough?

The answer to both these questions is now clarified in this latest Judicial Review decision from the High Court which underlines how, in respect of the “low arguability threshold” for Art 2 engagement, low really does mean low. But, before any commentary, first a confession: this blogger could not stop herself fangirling Mrs Justice Hill as she read through this judgment.  It is a beautiful exposition of how to write a clear and accessible judgment.  It is long, at 46 pages, as Hill J is no slouch and the factual analysis is quite detailed. But her Ladyship’s “Article 2 in overview” section (see paras 14-37) is as clear an exposition of the relevant law on the engagement of Art 2 procedural duties as you will find anywhere. Indeed, inquest practitioners might as well just copy and paste the text into their skeleton arguments (or coroners into their own judgments) to save themselves a lot of time,  as it is really not worth trying to explain this complex law any more succinctly than you will find in Hill J’s 23 neat paragraphs. It would be ridiculously presumptuous for this blog to even try to summarise it any further, beyond noting that Hill J clarifies that the low threshold of ‘arguability’ which will engage the procedural Art 2 duty applies not only to the question of any breach of a substantive art 2 duty, but also to whether any duty arises in the first place.

The meat of this case is, as with many cases, the application of the law to the unique facts and looking at whether the coroner had correctly applied that low arguability threshold in coming to his decision.

READ MORE

R (Drysdale) v HMAC Manchester (South) [2025] EWHC 1850 (Admin) 18 July 2025, judgment here

To what extent an inquest must investigate possible causes of death is often a perplexing question. Until oral evidence is explored in a hearing it may not be known whether a possibility will crystallise into probability and so lend itself to a meaningful inquest conclusion.  In this case the criticism levelled at the coroner was that he had prevented some questioning of an expert and so not permitted relevant possibilities to be explored.

Although there was some limited research evidence supporting a possible correlation between the prescription of an anti-psychotic drug and the development of fatal leukaemia, the judge was not persuaded the coroner had been wrong when he exercised his r.19(2) power.

Once the expert had confirmed the evidence of a causative association was scant, the Area Coroner had been correct to prevent additional questioning on the issue.  There could not have been any meaningful inquest conclusion based on the expert evidence, since it revealed no more than a theoretical possibility which could not support factual or legal causation.

His Majesty’s Senior Coroner for West Yorkshire (Western District)  [2025] EWHC 1672 (Admin) 3 July 2025. Judgment here

This Divisional Court judgment recounts what should have been a completely uncontroversial application under s.13 Coroners Act 1988 for a fresh inquest.   Some highly relevant evidence had come to light which was not before the Coroner at the first inquest. Once made aware of the new information the Coroner understandably took the view that this new evidence would likely lead to a different inquest conclusion.

What makes this simple and uncontested case rather remarkable is how long it has taken for the right thing to happen and for an order for a fresh inquest to be made. The new evidence was discovered and put before the Coroner within six months of the initial inquest concluding.  Yet it was a further six years before that fresh inquest could be granted by the High Court.

Most (but by no means all) of the delay seems to have been occasioned by delays at the Attorney General’s office.  This so concerned  the Divisional Court that their Lordships announced at the end of their judgment that the Court would be sending a copy of their judgment to the Attorney-General himself, so he might be aware of the Court’s view that the delay in granting the Coroner’s request for a fiat would not only have caused further unnecessary anxiety to the deceased’s family, but may have had an adverse impact on the quality of the evidence available at the fresh inquest that is yet to be held.

Baron Hermer may now be rather peeved to be receiving a nudge from the High Court about something that was clearly not his own doing – but if the judicial nudge results in s.13 fiat applications being speeded up in future this can only be a good thing.