R (Henshaw) v Assistant Coroner for Derby and Derbyshire [2025] EWHC 357 (Admin), 20 Feb 2025,  judgment here

As is often said, ‘when things go bad, they arrive in threes’.  And when three things do arise you really wouldn’t want them to be in a case which was already (as Mr Justice Jay remarked) “…a difficult case that would have challenged even the most experienced of coroners”:

However the bad tidings for the Assistant Coroner in these Judicial Review proceedings might helpfully allow other coroners to learn how:

• Not to direct a jury that they must first consider returning a traditional short form conclusion before returning any narrative;
• Not to overlook the decsion in Tainton[1] when dealing with admitted failings; and that
• If you do refuse to call a witness, make sure it is for the right reason.

What inquest lawyers should also note is that the approach of the High Court to re-running a complex inquest is grounded in pragmatism.  Even if three things do go wrong, one does not always a need to hold a fresh inquest to put them right. Here the jury directions had been unclear and the Claimant achieved a declaration validating two of her other complaints, but none of these slip-ups were significant enough to require the original inquest to be quashed.

Whittle v HM Coroner North West Wales [2025] EWHC 236 (Admin) judgment here

What were you doing on 24 November 1994? Can you describe the things you said or heard  that day or explain the rationale for any significant decision you made.   If I tell you that is the year Nelson Mandela was first elected president of South Africa, Kurt Cobain died and Forrest Gump was released does that help you at all?

On rare occasions a judgment of the High Court in an uncontested case will provide very little explanation of what has gone on to lead to the decision.   Yesterday a judgment was handed down in such a case.  Rather unsatisfyingly it is not really explained how or why the Senior Coroner here “encouraged”, the Claimant’s application to hold a fresh inquest into the death of a psychiatric patient so many decades after his first inquest ended, or perhaps more appositely, how the fresh inquest that has now been ordered can fully, frankly and fearlessly investigate this death, and compensate for  the inadequacies of the first, if there are now no medical records remaining, no witness statements, no details preserved of staff involved  in events and any witness still living will have to recall matters that occurred three decades ago.

R (Glaister & Carr) v HM Asst Coroner for North Wales. [2025] EWHC 167 (Admin) (here)

The decision whether and how to leave an unlawful killing conclusion for the jury in respect of a 16 year old falling from a mountainside on an explorer scout weekend overseen by volunteer scout leaders was always going to be both complicated and controversial.

When there needed to be a third go at holding the inquest – the first jury having been discharged after the court was misled, and the second inquest also being abandoned for material non-disclosure (with an IP later apologising to the bereaved in open court for its lack of sensitivity and the defensive stance it adopted), the writing may have already been on the wall that this case was rather extraordinary.

When you also learn that the inquest eventually involved 32 days of hearings, topped off by the coroner holding a court hearing on a Sunday to deal with legal submissions, before taking two days to deliver his summing up, handing 20 pages of written directions to the jury, then you may feel little surprise that this case ended up in the Admin Court for a second time challenging the conclusion. (For the first trip to the Admin Court see our earlier blog here)

The resultant judicial review decision will not disappoint those who love delving into legal complexity. Any coroner or inquest advocate grappling with applying the elements of gross negligence manslaughter in a coronial setting and who therefore needs to understand: (i) the Adamoko criteria [1] ; (ii)  the Broughton threshold [2]; (iii) the Kuddus chance of risks [3];  and (iv) the Rose trap [4] (v) along with its ‘flags’, will certainly benefit from reading the first 38 pages of Fordham J’s decision it in its entirety.

The Chief Coroner, HHJ Alexia Durran, has today launched the “Chief Coroner’s Guidance for Coroners on the Bench” 

It has been produced as a resource for coroners to help them locate key principles, practical information and precedents when dealing with inquests, but of course will also be an invaluable reference point for all inquest practitioners.

As guidance it is not legally binding and does not replace the need for coroners and those appearing before them to conduct their own legal research. There will be times when the guidance is departed from for good reason. It holds the same status as the Chief Coroner’s existing guidance notes and law sheets, and has been issued to promote consistency and encourage best practice.

“In English law a person’s name is that by which he himself chooses to be known.”[1]

Despite Baroness Hale’s very clear statement it remains a surprise to some to learn that we have no ‘legal name’ under English and Welsh law. The identity of a person is not a matter of legal formality in that without any legal formality required anyone might reject the name they were given at birth, and that others have known them by, and adopt a new name.  A name appearing on one’s birth certificate does not create a ‘legal name’ for the simple reason that in this jurisdiction we do not have a ‘legal name’.

Of course most people do choose to retain and introduce themselves to others using the name given to them by their parents at birth, but there is no requirement to do so.  Any person aged over 16 may choose to adopt a new name at any time in their life for any reason, or for no reason at all.[2]

Families are therefore often surprised to learn that there is also no requirement in law for a deceased’s name as recorded and certified by the coroner at their death to correspond to the name that appears on their birth certificate.  As a judge of the High Court Chancery Division recently observed^[3] “there was nothing improper in allowing the deceased to be buried under the name which he had always used since he had lived in the UK. Although it was not the name which he had been born with.”   (Of course we are not actually ‘born with’ a name.  We are simply given a label by someone else shortly after our birth.)