Are presumptions and burdens of proof relevant in inquests? Insanity and unlawful killing considered

R (Bryan) v HM Assistant Coroner for Buckinghamshire [2024] EWHC (Admin) 26 12 January 2024 (judgment here)

This most tragic of cases concerned the loss of two precious and irreplaceable lives when Ms Redmond put herself in the path of a train whilst holding her three year old daughter.

The inevitable conclusion of suicide in Ms Redmond’s inquest was not contested.  But the Coroner did not agree with the position of the Claimant (supported by the paternal side of the child’s family) that the child had been unlawfully killed by her mother.  In a long and detailed narrative conclusion regarding the child’s death the Coroner addressed her mother’s state of mind and determined that this was not an unlawful killing because Ms Redmond had probably been ‘insane’ when she had jumped.

The Claimant challenged both the form and substance of the Coroner’s conclusion, arguing that the Coroner’s finding had impermissibly reversed the presumption of sanity and, in its place, substituted a presumption of insanity.  The challenge failed on all grounds, however, as the Court held that not only was the Coroner entitled to make this finding on the evidence but, given the inquisitorial nature of an inquest, it would be inappropriate to attempt to transpose directly the concepts of a presumption of sanity and the burden of proof as they apply in the context of criminal proceedings to the very different context of inquisitorial coronial proceedings.

The Inquests

The conjoined Article 2 inquests that followed these two deaths had been protracted and complicated. There were ten interested persons with evidence admitted from 68 witnesses and 2,000 pages of documents to consider. The inquests’ scope addressed Ms Redmond’s mental ill health, looking at her behaviour over the months before the deaths and her interaction with various social and medical services.  Evidence ranged far and wide, including very detailed analysis of her movements and state of mind alongside the investigation of other concerns related to the circumstances of the deaths and the public bodies’ involvement with the family.

At the end of the child’s inquest the Coroner had stated in his narrative conclusion that “it was not possible to determine that [Ms Redmond] was not suffering from such a disease of the mind as to be incapable of distinguishing between right and wrong and was therefore likely to be legally insane.”

The Judicial Review grounds

Two challenges to this narrative conclusion were raised by the Claimant:[1]

  • that the Coroner erred in law by mistakenly adopting the presumption that Ms Redmond was insane at the time of the incident when he should have adopted a presumption of sanity; and
  • that returning anything other than a short-form conclusion that the child was ‘unlawfully killed’ was irrational.

The Claimant submitted that the Coroner’s approach impermissibly reversed the presumption of sanity that the Coroner should have adopted and, in its place, substituted a presumption of insanity.

A presumption of sanity or of insanity?

It was not contested by the Claimant that there was evidence of episodic mental disturbance that may properly have led to a finding of insanity if the act had happened at some other time.  But the Claimant asserted that the Coroner, despite having identified deliberate acts by Ms Redmond, had mistakenly adopted a presumption of insanity and applied this to the time of the deaths.

The Court however disagreed, holding that the question of insanity must fall to be considered by a Coroner if there is evidence that properly raises it.

The relevant criteria for the determination of sanity/insanity are found in the M’Naghten rules, which in summary state as follows:

(1) Everyone is presumed to be sane, and to possess a sufficient degree of reason to be responsible for their crimes, until the contrary is proved.

(2) To establish the defence of insanity, it must be clearly proved that, at the time of committing the act, the accused was suffering such a defect of reason, from a disease of the mind, as not to know the nature and quality of the act they were doing, or, if they did know it, that they did not know that what they were doing was wrong.

In a criminal setting it is clear that the presumption of sanity must be the starting point; and so the burden of proof lies upon the accused to establish on the balance of probabilities that the requisite defect of reasoning was present. However Lord Justice Stuart-Smith, giving the judgment of the Court, considered that such presumptions and burdens were wholly inapplicable in the context of inquests due to the nature of coronial proceedings.

In an inquest there is no defendant and therefore no one upon whom the relevant burden of proof might lie. As an inquisitorial, non-adversarial, fact-finding inquiry the rights and protections afforded to a person accused of a crime in criminal proceedings are absent in an inquest where the same person is suggested to have acted unlawfully.

In the inquisitorial context the concepts of presumptions and burdens of proof are particularly inapposite to be applied to the deceased person or to interested persons for basic reasons of fairness (this being particularly important where the person whose conduct is at issue is themself deceased).

The approach required at inquests

The judgment goes on to explain that when addressing the question of insanity in the context of a possible finding of unlawful killing the two questions for the Coroner should be:

(1)   whether, on all the available evidence, the issue of insanity is properly raised and then if there is sufficient evidence of insanity for it not to be withdrawn from consideration? (either by the coroner or, if there is one, the jury)

(2)   whether, on all of the relevant evidence, the correct conclusion on the balance of probabilities is that the person in question was not insane?

No burden of proof is required to address those questions. Rather, this approach preserves the protections required by the considerations of fairness. If it was more likely than not that the person was insane at the time of committing the act that led to the death in question, a conclusion of unlawful killing would be unsafe and so should not be reached.

The Claimant had also argued that a finding of insanity it was incompatible with the Coroner’s factual finding that Ms Redmond’s actions at the railway station were deliberate.  But as the Court found, a person’s continuing capacity to act deliberately is not necessarily removed when they are in the grip of a psychosis and so is not determinative of the issue of insanity.  The Coroner’s conclusions were well within the bounds of conclusions which were open to him on the available evidence.

The Narrative Conclusion

The court commented that such a detailed, complicated and sensitive case, particularly in relation to Ms Redmond’s state of mind, had fully justified the Coroner’s decision to give a narrative conclusion.

That conclusion was however described by the Court as “less than immaculately expressed” as in seeking to follow the advice of §32 of the Chief Coroner’s guidance on Unlawful Killing the Coroner had introduced a “clunky” double negative.

However, the Court considered that it was reasonably clear that the Coroners findings were that (a) he was not satisfied that Ms Redmond was not insane at the time of the act, and (b) he was satisfied that she was likely to have been insane at the time of the act.

In such a tricky case as this one, one’s narrative conclusion being  “less than immaculate” is perhaps a criticism most coroners would be happy to live with.




[1] The Chief Coroner was also drawn into the proceedings as an interested party, as paragraph 32 of the Chief Coroner’s Law Sheet: No. 1 on Unlawful Killing also came under scrutiny.