R(AH) and R(IS) v Secretary of State for the Home Department [2025] EWHC 3269 Admin,  judgment (15 December 2025) here

Article 2 ECHR encompasses a ‘systems duty’ which requires public bodies to protect all citizens by having both appropriate state regulation and functional procedures and policies in place to offer protection where life might otherwise be at risk. Spotting flaws in a system is an important exercise for inquest lawyers, as when death arises from an arguable breach of the systems duty this will trigger a ‘Middleton’ ‘Article 2 Inquest’.

However it can sometimes be tricky to spot whether what one is looking at is an error by an individual in how they have operated the system in question (which is not a systems breach), rather than a flawed or wholly absent system (which is).  Someone operating within an adequate well-functioning system and making a mistake (even a very bad one) is insufficient for a systems failure. A single cog failing to turn within an otherwise functional and well well-oiled machine will not reach the standard necessary to show a breach.

However, this judgment by Mrs. Justice Jefford might make you think again about when repeated individual failings might reveal more than someone simply having a bad day at work, but actually reveal that the system although capable of working effectively was not being implemented and so was not working effectively. Where the failure is not in the system’s design, but in ensuring the implementation of the system an ECHR systems breach may still be made out.

R (Olabode) v HM Area Coroner for Manchester City & Manchester University NHSF Trust (2026) EWHC 810,  2 April 2026, judgment here.

Coroners and inquest practitioners seeing this 31 page judgment land on a Maundy Thursday need not worry that they might now have a lot of reading to interrupt their Easter break.  Despite the lengthy, detailed and erudite judgment of Mrs Justice Hill this case does not develop coronial law one iota – it is a case uniquely confined to its facts.

But gosh! what an incredibly complex set of facts these were.   Indeed Hill J is rather playing down the intricate detail she had to grapple with when she opens her judgment saying that “this claim has involved the consideration of incredibly detailed expert evidence”.  There were eight experts from seven specialist medical disciplines who provided their views to the Coroner on cause of death and causation during the inquest under challenge.  Inevitably they did not all agree with each other: indeed they agreed and disagreed in different ways on different things. The medical evidence was so convoluted that those present in the Admin Court in Manchester last week report that a far more apt reference was made at the hearing to “needing a towel on the head” before one might even begin to understand it.

As anyone who was not born this century ought to know, a towel is of course about the most massively useful thing an interstellar hitchhiker can have.[1]  But happily you won’t need your own towel here, as Hill J has done all the hard work for you. Just jump to paragraph 113 to find the single learning point for coroners and inquest practitioners that comes out of this case, which is:

When inquest evidence is this complicated, and even if Art 2 is not engaged, it’s a jolly good idea for counsel to help out the coroner by proposing a list of key issues that the coroner should consider and cover off when coming to their findings of fact.

And then perhaps also join your blogger in celebrating the forensic analytical skills of both the Area Coroner for Manchester City and Hill J[2] next towel day, on 25 May (assuming there is no appeal, in which case three more towels will probably be needed).

Drake’s Application for Judicial Review [2025] NIKB 70, 12 December 2025, judgment here.

It is clear that litigation privilege cannot arise in respect of reports commissioned for a coroner’s inquisitorial proceedings: the Northern Ireland Court of Appeal (NICA) have already soundly dealt with that point.[1] Bound by House of Lords authority, the NICA held that if an expert report is obtained only for the purpose of an inquest, then no privilege will apply to it.

However, in Ketcher & Mitchell,[2] the NICA made it clear this was their extremely reluctant position. The court gave rather a strong steer that the position of a family who refuse to provide their own expert report to a coroner should usually prevail, even in the absence of privilege.

That position is now re-analysed in some detail in this more recent NI High Court decision.  McLaughlin J explains why the position is far more nuanced than Ketcher & Mitchell might suggest at first glance. There is no global principle of non-disclosure and the Coroner in Drake’s Application was entitled to require disclosure to her of a non-privileged expert report commissioned by the bereaved.

Although this case concerns Northern Irish Coronial legislation the disclosure principles discussed here are very likely to apply with equal force to the similarly worded provisions of schedule 5 CJA 2009 in England and Wales – making this case essential reading for anyone with an interest in how privilege and disclosure might operate in our Coroners Courts.

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.