Justice neither done, nor seen to be done, in a secret inquest

Senior Coroner for Cumbria v Ian Smith [2015] EWHC 2465 (Admin)

Poppi Worthington, was only 13 months old when she died in hospital in December 2012 having apparently sustained fractures to her leg and other injuries. Yet despite there clearly being reason to suspect that this was a violent or unnatural death, and an inquest already having been held, none of the facts surrounding her death have as yet been made public. Poppi’s inquest in October 2014 took only seven minutes to complete; the Coroner returned an open conclusion and found that her cause of death was ‘unascertained’. It is hardly surprising then that the High Court has now overturned that first inquest and determined that a fresh inquest should be held.

“The Coroner did not give any information about the circumstances leading to the girl’s death. The inquest did not address questions about her welfare, how she was discovered, whether any attempts were made to revive her and whether any public agencies were at fault.”

This case re-emphasizes the duty of coroners to hold their inquests fully in public no matter how difficult the surrounding circumstances. Moreover, that this case had to be brought by the present Senior Coroner against the previous Senior Coroner brings into question whether there should be some simpler mechanism than requiring a Senior Coroner to, firstly, seek a fiat of the Attorney General and, secondly, make a High Court application under s.13 Coroner’s Act 1988 when he or she seeks to put right obvious shortcomings and hold a fresh inquest.


Poppi died in hospital after her parents had called an ambulance to her home; she had apparently sustained fractures to her leg and other injuries. There were other children of the family and so, in March 2014, in the course of proceedings in the Family Division concerning her siblings’ welfare, Mr Justice Jackson heard evidence from three pathologists and made findings of fact in relation to the injuries to Poppi. However the judge then embargoed his judgment to avoid prejudice to potential criminal proceedings. An anonymity order was in place to prevent the identification of Poppi’s mother and her siblings, although her father could be named. Mr Justice Jackson did however envisage that his judgment would eventually be made public.

An inquest was held in October 2014; at the time the local children’s safeguarding board was also conducting a parallel investigation. No evidence was called at the inquest, instead the defendant Coroner, who had a transcript of the Family Division judgment, indicated that he had taken account of the judge’s findings of fact. The Coroner did not reveal what those findings of fact were, nor did the record of inquest record them under “the circumstances of death”.

The new Senior Coroner applied for a fresh inquest, arguing that the statutory duty had not been fulfilled.

Additionally, in April 2015 new expert evidence from inter alia a forensic pathologist regarding the post-mortem findings led to the rare step of a re-opening of the Family Division’s fact finding[1] which has been listed to be reconsidered in November 2015. This clearly raises the possibility that the conclusion might be different following a new inquest.

The decision 

On 23 July 2015, the High Court unsurprisingly quashed the record of the inquest and ordered a new investigation under s.13 Coroners Act 1988. LJ Burnett emphasised that inquest hearings must be held be in public (save for in limited circumstances that had no application in this case). This death required a public investigation yet the Coroner had failed to perform his central function: he had not recorded findings of fact and he had taken evidence in private in circumstances that were not permitted.

Whilst the court sympathised with the defendant Coroner’s position, as he found it difficult to have an inquest with parallel family proceedings and a police investigation in train, these difficulties could have been avoided if he had adjourned the matter until after the embargo. It was clear that a fresh investigation and inquest should be held and this would take place after a new fact finding hearing had been completed in the Family Division.


The approved judgment in this case is still awaited, but it appears that the call for a new inquest came from the media. Lawyers for newspaper groups, failed in a March 2015[2] bid to persuade the Family Division to publish the original fact finding and were concerned at the lack of any public hearing of this case in any forum. As the Guardian reported at the time of the inquest:

“The Coroner did not give any information about the circumstances leading to the girl’s death. The inquest did not address questions about her welfare, how she was discovered, whether any attempts were made to revive her and whether any public agencies were at fault.”[3]

It seems that the pressure was further increased when, also in March this year, Cumbria Police announced that criminal proceedings were not being taken against either of Poppi’s parents – hence there seemed little prospect of any of the circumstances of her death being scrutinized in a public court.

The press were understandably concerned at the secrecy surrounding the entire case noting that the “far-reaching injunction” of the Family Division prevented the media from even revealing the identity of the hospital in which Poppi died. Additionally, the Cumbria Police force had since referred itself to the IPCC and had suspended an officer over alleged failures in the police investigation of the death, the details of which were also not in the public domain.

Against this background an inquest that took just seven minutes to deliver an open conclusion with an unexplained cause of death and with no meaningful findings of fact recorded was clearly wholly unsatisfactory.

It nevertheless still took the Senior Coroner some months to secure a fresh inquest through the present two-stage procedure. The fiat of the Attorney General acts as a permission stage on s.13 proceedings. Whilst the fiat stage is very useful for weeding out unmeritorious or vexatious applications by interested persons, this author knows of no occasion when a Coroner’s application has been refused a fiat by the Attorney General. In Judicial Review proceedings the court has the often used discretion to consolidate the permission stage and substantive hearing; but this can not be done under s.13. Sensible law reform should perhaps consider the removal of the need for the AG’s fiat in cases where a Senior Coroner is making the s.13 application. No Senior Coroner is likely to make a wholly unmeritorious application, and so both time and the public expense of the fiat application could simply be saved.

[1] http://www.bailii.org/ew/cases/EWFC/HCJ/2015/35.html

[2] http://www.bailii.org/ew/cases/EWHC/Fam/2015/918.html

[3]  http://www.theguardian.com/global/2014/oct/21/poppi-worthington-cause-death-2012-unexplained-cumbria-coroner