Fresh inquests required where issues regarding dangerous appliances had not been addressed 

Smith v HM Coroner for Cornwall (2015) 22/10/2015

The important role a coroner’s inquest has to play in elucidating factors relevant to the death in a way that might then allow for the greater protection of the wider public is exemplified by this recent decision of the Divisional Court. Inquests into two deaths from carbon monoxide poisoning were overturned where full information regarding the knowledge and correction of a design fault in the gas cooker thought to be responsible had neither been available nor explored.

Mr Smith and Mr Branton were friends and housemates. It appeared that in November 2010 they were trying to warm a pie in the oven and had accidentally turned on the grill instead of the oven. A design fault meant that the grill could easily be operated with the oven door closed and the efficiency of the door seal was such that the gas from the grill would then burn in an environment with insufficient oxygen leading to a consequent build up of carbon monoxide. The men were found dead in their home from carbon monoxide poisoning – with CO readings in the upstairs rooms showing an exceptionally dangerous level. At the joint inquests into their deaths in December 2012, where neither their families nor the cooker manufacturers were represented, a verdict of accidental death was returned by a jury.

The cooker had been produced and distributed by Beko and was provided with an instruction booklet which stated that the grill should not been used with the door closed, but which did not explain why. There were no other safety features in that respect, nor were there any warning notices on the appliance itself.

A report provided to the inquests indicated that Beko were now aware of the design problem and taking some action. However, the witness had assumed that the cooker had been purchased before the extent of the manufacturing problems was known. Evidence that emerged after the inquests suggested this was not the case. New evidence revealed that a number of other people had died in similar circumstances in late 2008 and that the problem with the cooker, which had first arisen in Ireland, was known of by Beko before the applicants’ sons’ cooker had been bought in England.

Action had been taken in Ireland going beyond that taken in the UK, in that distribution of the cookers had been halted in Ireland. The media campaign in Ireland had also been far more widespread with notifications made directly to 1.9 million householders and the cookers already sold had been recalled. In the UK unsold cookers had been modified, but those already sold were not dealt with, although the safety modification required was said to be as simple as a qualified engineer cutting the seal around the door with a pair of scissors. Despite Beko endeavouring to inform customers of the risk in 2009 via notices in the UK press the applicants’ sons had not been notified.

The parents obtained a fiat of the Attorney General to apply under s.13 Coroners Act 1988 to quash the inquests and for fresh inquests to be held. Furthermore, it was known that three inquests were due to be held in March 2016 in the same coronial jurisdiction into another similarly fatal incident (the death of three members of the Cook family as a result of CO poisoning in 2013 thought to be caused by a different cooker produced by Beko), the bereaved parents applied for all five inquests to now be linked and held concurrently.

The application, which was unopposed, was granted by the Divisional Court (Ouseley J & the Chief Coroner). The court noted that the coroner’s approach to the initial inquests had not been criticized. She had not excluded evidence which should have been considered, or included evidence which should have been excluded nor had her inquiry been insufficient. However fresh evidence had emerged since the original inquests which meant that it was desirable and necessary in the interests of justice to quash the verdict and order new inquests.

The interests of justice being the touchstone of any s.13 decision[1] it mattered not whether a different conclusion from ‘accident’ might be returned. There was new evidence and justice required that the full extent of it should be publically revealed.

The court also approved of the fresh inquests being linked to the forthcoming inquests into the 2013 fatality, as there was a significant degree of overlap.


This case yet again emphasises that where an inquest has not been able to fully investigate important circumstances relevant to a death then the interests of justice are likely to require a fresh investigation. As Beko did not participate in the initial inquest there appears to have been very little disclosure regarding the extent of Beko’s knowledge at the material times.

Whilst the court re-emphasised how there is no need for a different verdict to be the probable outcome to justify a fresh inquest – given the history of the present case one can foresee that a conclusion as serious as corporate manslaughter might be under consideration and at the very least the court may wish to consider the use of a narrative conclusion that would be far more illustrative of the circumstances of these deaths than a simple descriptor of ‘accident’.

It is understood that the legal representatives of the family now propose to seek the assistance of the Chief Coroner to contact all Coroners who may have knowledge of carbon monoxide deaths related to similar appliances. Clearly such sharing of knowledge and the potential for further public investigations by means of fresh inquests in other cases could be instrumental in preventing further fatalities in the future from any unmodified and hence potentially dangerous appliances that may still be in active use.



[1] See the Hillsborough Inquests s.13 decision: Attorney General v HM Coroner S Yorks [2012] Inquest law Reports 143


Author’s Note: The extempore judgment is, at present, unreported and I am grateful to Leigh Day who represented the applicants and who provided the UK Inquest Law Blog with additional information regarding the s.13 application.

Anyone wishing to provide any information about similar fatalities to Leigh Day may contact Solicitor Thomas Jervis directly on 0207 650 1181 or via e-mail at