R(Bailey) v HM Senior Coroner for East London [2025] EWHC 1637 (Admin) 30 June 2025 (judgment here)

Once the investigative obligation under Article 2 ECHR is engaged an inquest will most often be the means by which the state will satisfy the procedural obligations that follow. However in situations where the inquest has been suspended due to a homicide trial then the Coroner considering whether to resume an inquest will always need to consider whether other investigative procedures of the state that have already been conducted have, collectively, satisfied the requirements of the procedural obligation.

The principles of law involved are now relatively clear. The Art.2 procedural obligation requires a state, of its own motion, to carry out an investigation into a death that: (i) has a sufficient element of public scrutiny of the investigation or its results; (ii) is conducted by a tribunal that is independent of the state agents who may bear some responsibility for the death; (iii) allows the relatives of the deceased to play an appropriate part in it; and (iv) is prompt and effective.

The more difficult question is how to apply that law in practice, when each case must be looked at on its own unique facts. As readers of this blog will know, in Silvera the pre-inquest investigations had not been enough.  In Grice there had already been sufficient independent examination of state shortcomings for the Art.2 obligations to have been satisfied without an inquest.

This recent High Court decision adds some more colour to the complex picture. There is not really any new law here, but there is a helpful insight into how the court might approach the issue when a Coroner declines to hold an Art.2 inquest, believing enough has already been done.

R (Metropolitan Police Commissioner) v Police Conduct Panel [2025] EWHC 1462 (Admin)  17 June 2025,  judgment here

Skeleton arguments and written submissions are often emailed to coroners in advance of an inquest or PIRH.  The document is rarely read out in court in full, and so any press or public sitting in court may find the resulting arguments extremely difficult to understand or follow when only partial extracts from the written document are elliptically referred to in oral submissions.

In such circumstances how are those who are entitled to attend the open public inquest hearing supposed to understand the arguments relied upon by the different interested persons or to make sense of the coroner’s ruling on a relevant matter?

This recent decision by Fordham J, reminds us that, whatever the forum, open justice requires judges and tribunals to ordinarily make skeleton arguments relied upon at a public hearing available to the press promptly if requested at that hearing.  To do so promotes open justice, as to both public scrutiny and intelligibility. It also promotes contemporaneous reporting and public confidence.

Tindall and another v Chief Constable of Thames Valley Police [2024] UKSC 33, (judgment here)

It is not coronial law under the microscope here, but rather a decision from the Supreme Court at the end of last year in a police civil action.  Nevertheless it provides helpful insight into the potential responsibility of police forces in their deployment to incidents that coroners and inquest practitioners will need to bear in mind should  a neglect or gross negligence manslaughter/unlawful killing conclusion be under consideration.

The Supreme Court was concerned with the test for the imposition of a duty of care in a civil claim for compensation.  The Court considered the elusive dividing line between ‘failing to protect a person from harm’ (where no duty of care arises) and ‘making matters worse’ (when a duty does bite). The Court acknowledged that drawing this distinction is “not always straightforward” [1] – which is perhaps something of an under-statement!

Thompson’s Application for Judicial Review [2025] NICA 25 (Judgment 13 May 2025, here)

Whilst the context of this case concerns the grant of anonymity, it has much wider relevance as it addresses the legal issue of identifying the precise point at which a coroner will become functus officio, such that they can no longer take any steps related to an inquest.

That cut off point is important to know, given the power of a coroner to change previous procedural decisions generally only pertains whilst the inquest is still current[1] and so any review or amendment of an earlier coronial decision must be completed before the inquest is closed.

The specific question that arose in this case was whether a review of a grant of anonymity might be conducted after an inquest had concluded.   Spoiler alert: No it can’t. So both counsel and the coroner should be alert to the need to deal with this issue before the inquest ends.

Morrow v HM Assistant Coroner for Merseyside [2025] EWHC 935 (Admin) 15 April 2025 judgment here

What the bereaved hope might be investigated at an inquest and what the inquest actually explores are often very different things.    In this recent case the Assistant Coroner’s decision to draw a very tight investigatory scope was upheld by the Divisional Court.  There is no new law here.  Coroners have a wide discretion regarding scope and that discretion was properly exercised. The Coroner was entitled to have heard only limited evidence related to events very close to the time of death.

However there is still a lot to be learned from this case regarding how to avoid later conflict by bearing in mind the difficult position of an unrepresented bereaved family; seeking their views appropriately; managing their expectations by ensuring they fully understand the process;  providing them full explanations of why an inquest’s scope might be narrowly drawn along with the reasons for relevant coronial decisions.