Toogood v HM Senior Coroner for Somerset  [2026] EWHC 634 (Admin) 17 March 2026,  judgment here

Suicide is usually a covert act. In the absence of a final letter or a recent and clear declaration of suicidal feelings, there will often be no direct evidence of what the deceased intended by an action that sadly proves fatal. To what extent then might a coroner draw reasonable inferences from established facts, and decide that a deceased intended the natural and inevitable consequence of their actions?

This Judicial Review challenge grappled with the question of the inferences that can be permissibly drawn by a coroner where the deceased has made no statement of intent. Importantly, Sweeting J’s decision is the first since the Supreme Court decision in Maughan to confirm that earlier authorities, which stated that suicide could only be found if all other explanations had been excluded, are no longer good law. Those earlier cases hinged on the need to achieve a criminal level of certainty, which is no longer required for a finding of suicide.

Crucially, suicide still must not be presumed: there must be some evidential foundation for a conclusion of suicide. However, a coroner may draw inferences from circumstantial matters and is not confined to direct evidence. Indeed, suicide may be inferred from the mode of death alone. All that is required is a determination of what probably occurred based on the totality of the evidence and the reasonable inferences that may properly be drawn from it. As Sweeting J makes clear, a coroner is not obliged to exclude every alternative hypothesis, particularly speculative or remote ones, before coming to a suicide conclusion.

In the matter of an application by the Secretary of State for Northern Ireland for Judicial Review [2025] UKSC 47. Judgment 17 December 2025 here

More than 20 years ago 25-year-old Liam Thompson was shot and killed near a gap in a peace line separating nationalist and unionist neighbourhoods in Belfast. No one has ever been held accountable for his murder. Indeed, in the context of what the Supreme Court describe as “egregious and profoundly disturbing delays” there has still not been an effective and Article 2 compliant investigation into Mr Thompson’s death.

The abortive inquest that was commenced in 2023 has, however, given the Supreme Court cause to answer an important question of principle: What test, and what level of scrutiny, should be applied by a court reviewing a decision to disclose material over which a claim of Public Interest Immunity (‘PII’) has been made?

In a unanimous judgment, overturning the decisions of the Coroner, a High Court Judge, and two Court of Appeal judges, the Supreme Court affirms that the question whether evidence is covered by PII is a substantive question of the law of evidence, not an exercise of judicial discretion. A first instance court must determine where the overall public interest lies, by conducting the balancing exercise set out in R v Chief Constable of West Midlands Police, Ex p Wiley [1995] 1 AC 274.  The inquisitorial nature of an inquest will raise the stakes in PII cases as compared to civil litigation. If the first instance court misidentifies the public interest, it has gone wrong in law and an appellate or reviewing court is required to consider the balancing exercise itself and correct the error.

R (Rizvi) v HM Assistant Coroner for South London [2025] EWHC 3014 (Admin) judgment 17^th Nov 2025 here

It has been a long journey for Mrs Rizvi who may now have exhausted all avenues in her attempts to show that the police breached an Article 2 duty owed to her daughter.  Twelve and a half years ago Sabina Rivzi was the innocent victim of a gang shooting as she drove away from Bexleyheath Police Station, having picked up her boyfriend after a police interview.  A High Court judge has now forcefully concluded that, having held an Article 2 compliant investigation and inquest, the Assistant Coroner[1] was entitled to consider it unsafe to leave any findings of fact to the jury regarding acts or omissions by the police. The Claimant’s counsel’s “island-hopping expedition in a sea of extensive evidence” did not persuade Mr Justice Foxton that it was arguable that the Coroner’s assessment that it would be unsafe to do so had been unreasonable in the Wednesbury sense.

This case importantly delineates the ambit of the Art 2 procedural duty on coroners. It is exactly what it says on the label – a duty of procedure and not one of outcome.  It is quite a low threshold that triggers the procedural duty [2] to investigate an arguable Art 2 breach. But the hurdle to be surmounted before making any positive finding is somewhat higher once the evidence has been heard. In many cases a thorough exploration of all the evidence will reveal there is no state shortcoming that needs to be left to the jury, let alone reflected in the inquest’s conclusion.

A London NHS Trust v DT (by her litigation friend the Official Solicitor) and YT [2025] EWCOP 36.  21 October 2025, Judgment here 

Just occasionally a judgment from another jurisdiction can make you scratch your head very hard if you try and look at it through coronial eyes. This recent decision from the Court of Protection around brain stem testing and the neurological diagnosis of death has managed to leave your blogger with full blown dermatillomania.

But let’s first start with Schrödinger’s cat – a 90 year old thought experiment exploring superpositions in quantum mechanics (an entirely probabilistic system, which bears little relationship to the generally understood deterministic laws of physics that human life generally operates under). Radioactive atoms are considered by some quantum physicists to be in two states at once: decayed and not decayed and only switching to one of those to states when observed. To test this quantum theory Schrödinger sealed his theoretical cat in a box along with some theoretical unstable atoms and a batch of poison, thereby linking poor kitty’s fate to a random subatomic event. In the paradox the cat is to be considered simultaneously alive and dead  until the box is opened and its state is observed.

BUT NO, I hear you scream, life is deterministic not probabilistic, and therefore the cat is either alive or dead even before one looks in the box. On looking you are simply observing what already has occurred. It’s not that the cat is both dead and alive, it’s just that we don’t KNOW if it’s dead or alive.  Of course that was exactly Schrödinger’s point, as he sought to diss his fellow physicists with this fluffy feline paradox.

On one view of this present case, the law seems to have led the judge to approach the decision making regarding the unfortunate woman patient as if she too were a sub-atomic particle within a probabilistic system, who could be both alive and dead at the same time.

 

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.