Cogent evidence required before a fresh inquest is ordered

Bell v HM Senior Coroner for South Yorkshire King’s Bench Division (Administrative Court) 21 March 2023, [2023] 3 WLUK 342,

Hot on the heels of his decision as part of the appellate bench in Dove[1] last week, comes another foray into the question of the extent of the scope of an inquest into a likely suicide. The view expressed by William Davis LJ was very different on a different set of facts.

Here the claimant, rather ambitiously perhaps, sought a fresh inquest into his sister’s death some 30 years before. Her cause of death and what had happened to bring the death about were clear and not disputed. In December 1991 his sister (‘A’), who had suffered with poor mental health for some years, had stepped into the path of train leaving a final note for her family in her pocket. The inquest jury (as was required for a railway death in 1992) had applied the criminal standard of proof to suicide and returned an open verdict.

The claimant of course anticipated a likely suicide conclusion at any new inquest (now that only the civil test for the degree of certainty would be required) but what led him to seek a new inquest was (like the Claimant in Dove), that he wanted the cause of A’s distressed state of mind on the day that she died to be explored. The claimant considered that there was now fresh evidence going to that issue, and he urged the court to grant a fresh investigation and inquest into her death to look deeper into what had led A to behave as she had done.

A fresh inquest may of course be ordered where new evidence comes to light suggesting that the substantial truth of how someone came by their death has not been revealed. In Dove the Court of Appeal (including William Davis LJ) had found that new expert evidence which might elucidate why the deceased had taken her own life would justify a fresh inquest to explore that issue further. But here the basis for the application was not fresh evidence, but fresh speculation.  The facts now relied upon had been known to the deceased’s mother at the time of her death, and her mother had thought them not at all relevant to her death when she gave evidence at the first inquest three decades before.

The only basis on which a fresh inquest could be ordered under s.13(1)(b) was the discovery of new facts or evidence. As William Davis LJ made clear that did not mean any evidence: there had to be cogent evidence and inexpert speculation could not meet the statutory test.


A had been diagnosed as suffering from schizophrenia and had been detained under the Mental Health Act 1983. By January 1988 she was under outpatient care and working as a ward aid when she began a relationship with a student nurse at the same hospital. The couple lived in a flat in the hospital grounds and it appears that many people, including her treating psychiatrist, knew of their relationship. A became pregnant and underwent a termination in Summer 1988. The relationship ended shortly afterwards and by 1989 she had moved to Yorkshire to live with her mother. Her brother, the claimant, did not live with his mother at the time.

After A’s death in December 1991, A’s mother had given oral evidence at her inquest. She was aware of but did not mention the termination, and said that she knew of no reason her daughter would take her own life. A’s friend who had met with A on the day of her death also offered no explanation for A’s actions: that friend had since died.

In 1999, the claimant’s mother revealed his sister’s sexual relationship, pregnancy and termination to the claimant. Additionally, an investigation into allegations of abuse of other patients at the hospital (although not the deceased) had been conducted and concluded that there had been a systematic failure to prevent a culture of unprofessional and degrading practices towards patients at the material time.  At the claimant’s instigation A’s ex-partner was investigated by the police for an offence under s.128(1)(a) Mental Health Act 1959.[2] The man admitted having had a sexual relationship with A when a student, but he claimed it had been genuine and consensual and known of by others. The CPS concluded that prosecution of him was not in the public interest.

The claimant considered the termination was important fresh evidence of his sister’s state of mind at the time of her death: he postulated that she took her life on the third anniversary of what would have been the child’s birthday. This, he believed, was evidence of her likely distress at a ‘crisis pregnancy and termination’ arising from ‘an exploitative and inappropriate relationship’ with the student nurse in 1988.

When the present Senior Coroner was approached in 2017, she declined to apply for a new inquest.  She considered that there was no new evidence of the deceased’s mental state on the day of her death, only new speculation. Furthermore all the original documentation from 1992 inquest, as well as the relevant medical records, had long since been destroyed.

The claimant was therefore left to seek his own fiat from the Attorney General which he obtained in 2022 and brought his claim under s.13 Coroners Act 1988. He argued that: (i) the discovery of new evidence within s.13(1)(b) required a fresh inquest in the interests of justice; (ii) A’s death engaged the state’s procedural or operational obligations under Art 2 ECHR.

The Divisional Court’s view

When deciding a s.13 application the principles from the Hillsborough[3] case were to be applied: in considering whether to order a new inquest, the single question was whether that was necessary or desirable in the interests of justice. The ‘interests of justice’ was undefined, but the emergence of fresh evidence as to how an individual had met their death would indicate that the first inquest had been insufficient.

A had died more than three years after the termination, and there was no evidence whether, and if so how, those events had affected her on the day of her death. This was in stark contrast to the circumstances in Dove, where there had been fresh expert evidence from a psychiatrist that was relevant to causation of the death. All that there was here was the inexpert opinion of family members, whose observations on the impact of the relationship and the termination on A’s state of mind were pure speculation. The absence of cogent fresh evidence was fatal to the claimant’s application, a fresh inquest was not in interests of justice.

The Claimant’s argument that Art 2 obligations were engaged was also not sustainable. The state had not assumed responsibility for A’s welfare at the time of her death, or knew of any real and immediate risk to her in 1991: the essential features in Rabone[4] were not present. There was no possible basis to assert any operational duty owed to her under art.2.

The Senior Coroner had been correct not to concede the claim that was dismissed


Bridget Dolan KC of Serjeants’ Inn Chambers represented the Senior Coroner in this action.



[1] Dove v Assistant Coroner for Teesside [2023] EWCA Civ 289 – see our blog here

[2] Which made it an offence for a staff member of a hospital to have unlawful sexual intercourse with a psychiatric outpatient on hospital grounds (now repealed).

[3]  Attorney-General v HM Coroner of South Yorkshire (West) [2012] EWHC 3783 (Admin)

[4] Rabone v Pennine Care NHS Foundation Trust [2012] UKSC 2