His Majesty’s Senior Coroner for West Yorkshire (Western District) [2025] EWHC 1672 (Admin) 3 July 2025. Judgment here
This Divisional Court judgment recounts what should have been a completely uncontroversial application under s.13 Coroners Act 1988 for a fresh inquest. Some highly relevant evidence had come to light which was not before the Coroner at the first inquest. Once made aware of the new information the Coroner understandably took the view that this new evidence would likely lead to a different inquest conclusion.
What makes this simple and uncontested case rather remarkable is how long it has taken for the right thing to happen and for an order for a fresh inquest to be made. The new evidence was discovered and put before the Coroner within six months of the initial inquest concluding. Yet it was a further six years before that fresh inquest could be granted by the High Court.
Most (but by no means all) of the delay seems to have been occasioned by delays at the Attorney General’s office. This so concerned the Divisional Court that their Lordships announced at the end of their judgment that the Court would be sending a copy of their judgment to the Attorney-General himself, so he might be aware of the Court’s view that the delay in granting the Coroner’s request for a fiat would not only have caused further unnecessary anxiety to the deceased’s family, but may have had an adverse impact on the quality of the evidence available at the fresh inquest that is yet to be held.
Baron Hermer may now be rather peeved to be receiving a nudge from the High Court about something that was clearly not his own doing – but if the judicial nudge results in s.13 fiat applications being speeded up in future this can only be a good thing.
The background
On Christmas day 2017 Mr Pronesti was found hanging in the hallway of his home with cuts to his wrists. When his inquest was held in August 2018 the Assistant Coroner found that his death was “a result of his own actions…but there was insufficient evidence to indicate that he intended to take his own life”.
What the Assistant Coroner hearing the inquest did not know was that a package of relevant documents had been delivered to the Coroner’s Office some time before the inquest. Unknown to the Coroner, this package contained hundreds of pages of the deceased’s notes, messages, letters and drawings and included many references to his suicidal ideation.
The missing package
Months after the inquest, in December 2018, the package of documents was discovered in a drawer in the Coroner’s Officer’s office. It is not explained why it then took another two months before the documents reached the Assistant Coroner, but by 21 February 2019 (six months after the initial inquest) the Assistant Coroner had seen these mislaid papers. Having taken account of them his view was that he would probably have returned a conclusion of suicide had the documents been available at the inquest.
The only sensible response to this unfortunate administrative oversight was for the error to be put right by seeking a High Court order that a fresh inquest be held, thereby allowing for a different inquest conclusion to be considered.
It is not clear why a full year passed before anyone got round to making an application to the Attorney General for her fiat to proceed to the High Court. The Attorney General was eventually approached by the Senior Coroner on 27 February 2020.[1] Unfortunately, this was now on the cusp of the Covid-19 pandemic.
Four years delay
No one will be surprised (or critical) that some delay ensued as the pandemic took hold. But why it should take four more years before that fiat application was eventually granted is completely opaque. We are not told in the judgment whether the application for the fiat was contested by anyone, or whether, given the tardy response, it was ever chased by the Senior Coroner and, if so, what the response was from the Attorney General’s Office. By the time the fiat was eventually granted (on 15 May 2024) some four years and three months had passed. During that period five Attorney Generals had been in office.[2]
Further delay to service
Proceedings were now able to be issued by the Senior Coroner, who sent the part 8 claim to the court on 24 June 2024. However, because no defendant was identified on the claim form, it seems a further delay followed.[3] It took another six months[4] before that minor wrinkle was smoothed out, by which time the six weeks’ time period that is permitted between the granting of a fiat and serving the claim form on all interested persons was well expired.[5]
Relief from sanctions was now required. The court therefore extended the time for service of the claim form to 13 February 2025. By this time it was more than seven years since the death and over six years since the initial administrative error had been discovered.
The High Court hearing
At the Court hearing in July 2025 the Senior Coroner submitted (with wonderful understatement) that the importance of the missing documents “may be thought to be self-evident” as they “give rise to issues which ought to have been, but were not, investigated” and “the requirements of the procedural duty arising under Article 2 of the ECHR, may not have been met.” In less prosaic words the need for a fresh inquest here was a total ‘no-brainer’. Lord Justice Jeremy Baker and Mr Justice Butcher wholeheartedly agreed, remarking that the documents “were obviously relevant to the Assistant Coroner’s inquiry” as, on their face, they appeared to reflect clear suicidal ideation on the part of the deceased. It was necessary, in the interests of justice, that another investigation and inquest should now be held. The order sought was therefore given.
However, the Court was also keen to record its concern about the delay in granting the fiat in this case and to ensure the current Attorney General was aware of their Lordships’ view that such delay might cause unnecessary anxiety to the deceased’s family and have an adverse impact on the quality of the evidence available at the fresh inquest.
Should a Senior Coroner even need a fiat
This case illustrates how unnecessary delay can beset the process of a Senior Coroner obtaining a fiat to overturn an inquest. The role of the Attorney General is to filter out unmeritorious s.13 claims, and that gatekeeping function is of course important if High Court time is not to be wasted on hopeless applications. The reason for having such a filter is that the public interest might be damaged if s.13 proceedings could be brought by private individuals without any filter. In a case where an inquest has already been conducted, the filter also promotes the public interest in legal certainty.However, it must be exceedingly rare that an applicant Coroner’s judgment about whether a fresh inquest is necessary or desirable will be very wide of the mark.
Even when the process runs smoothly a fiat can take months to obtain. The delay inherent in the process of seeking a fiatmerely extends the waiting for families and increases administrative time and costs for Coroners. This case provides further support for a revision of the legislation so that a Senior Coroner seeking to overturn an inquest in their own jurisdiction would no longer need the Attorney General’s permission before they can bring a s.13 claim before the High Court.
POSTSCRIPT 11.7.25
With grateful thanks to Josuah Rozenberg and his always interesting and informative “A Lawyer Writes” blog, an update from the Attorney General’s office on this ubershambles is now available [6]. Rozenberg tells us:
“A week ago, I asked the attorney general’s office for a response. I was told yesterday that the delay — granting the fiat took more than 50 months — was caused by an “administrative error”.
I understand that the attorney general’s office has now introduced a centralised tracking system to monitor the progress of such cases. Senior officials receive monthly reports. And although there are no statutory deadlines, applicants and interested parties are asked to make any representations within a four-week timescale.
A spokesperson for the attorney general Lord Hermer KC told me:
The delay in this case should not have happened and we are sorry for the impact it has had on Leonardo Pronesti’s family and friends.
This administrative error occurred during the previous government. The way the attorney general’s office handles applications for fiat has changed significantly in the time since and we continue to monitor our processes so delays don’t happen again.”
Foonotes
[1] The Assistant Coroner had prepared and signed his witness statement in support of the fiat in October 2019 but a further four months passed before the Attorney General was approached
[2] Suella Braverman MP: Feb 2020-March 2021, Michael Ellis MP: March 2021-Sept 2021, Suella Braverman MP: Sept 2021-Sept 2022, Michael Ellis MP: Sept 2022-October 2022; Victoria Prentis MP: Oct 2022-July 2024.
[3] it is not explained why the Assistant Coroner did not apply for the fiat, making it clear they were seeking to overturn their own inquest. Or if a named Defendant was deemed necessary, why the Assistant Coroner was not named as the Defendant to the Senior Coroner’s application, and so avoid the additional months of delay. Where the coroner is making the application under s.13 they appear as the Claimant and, if correcting a shortcoming in their own inquest or their predecessor’s inquest, a defendant need not be named. In such cases the reason for the absence of a defendant should be explained on the claim form at the outset. Where the senior coroner applies to overturn an area or assistant coroner’s inquest it is simplest if that coroner is named (by their role, not in person) as the defendant.
[4] until 30 January 2025
[5] See CPR PD49E 20.3(3) a part 8 claim form applying under s.13 Coroners Act 1988 must be served upon all persons directly affected by the application within six weeks of the grant of the Attorney General’s fiat.
[6] Attorney general ‘sorry’ here