Morrow v HM Assistant Coroner for Merseyside [2025] EWHC 935 (Admin) 15 April 2025 judgment here
What the bereaved hope might be investigated at an inquest and what the inquest actually explores are often very different things. In this recent case the Assistant Coroner’s decision to draw a very tight investigatory scope was upheld by the Divisional Court. There is no new law here. Coroners have a wide discretion regarding scope and that discretion was properly exercised. The Coroner was entitled to have heard only limited evidence related to events very close to the time of death.
However there is still a lot to be learned from this case regarding how to avoid later conflict by bearing in mind the difficult position of an unrepresented bereaved family; seeking their views appropriately; managing their expectations by ensuring they fully understand the process; providing them full explanations of why an inquest’s scope might be narrowly drawn along with the reasons for relevant coronial decisions.
Background
Zoe Morrow was was found dead in her bedroom having consumed a quantity of prescription medication. The toxicology findings indicated the presence of alcohol and fatal levels of multiple drugs with overlapping adverse effects in her blood at the time of her death. Ms Morrow had been receiving NHS mental health care and after her death the NHS Trust’s review identified a number of gaps, shortcomings and missed opportunities in the care provided to her. However that review concluded that none had caused or contributed to her death.
The Inquest
Zoe’s family, like many others had not been legally represented at her one day inquest.
The Coroner had determined the inquest would have a narrow scope and he would answer the question “how” Zoe died by reference only to the physical cause of her death, rather than exploring the circumstances which might have led up to that point.
In line with this narrowly drawn scope the Coroner read a number of statements from witnesses under rule 23 from: family members; the pathologist; the paramedics who attended; the police officers who had attended when the body was discovered; a mental health nurse and consultant psychiatrist both of whom had been involved in aspects of Zoe’s care. The Coroner called only one live witness from the Trust, the Quality Matron for the Mental Health Urgent Care Services, who gave evidence by a remote video link. Her witness statement was only provided to the family very shortly before the inquest started and her evidence was mainly only relevant to the question whether the Coroner should make a Prevention of Future Deaths report following the inquest. The family were permitted to question her but were stopped at times when their questions went outside the inquest’s scope.
The Coroner concluded that the cause of Zoe’s death was ‘1A Mixed Drug Toxicity’. He rejected a conclusion of suicide as he was not satisfied of Zoe’s intent when taking the drugs. Instead he recorded the conclusion that this was a ‘drug-related death’ because the quantity of drugs within her system was the only thing which had caused the death.
The Claim
Some months later Zoe’s brother (on behalf of her wider family) obtained a fiat to bring a claim under s.13 Coroners Act 1988 seeking a fresh inquest. The family were of the view that shortcomings by the NHS Trust had contributed to the death and that various points had been were overlooked by the Coroner. They were aggrieved that the Coroner did not allow the family to give evidence, or question the two clinical witnesses about Zoe’s treatment by the Trust in the months leading up to her death and believed the Coroner did not properly consider whether Zoe’s death was a suicide.
However, Lady Justice Whipple found that there was nothing irregular in the inquest’s limited scope, saying that:
“As a matter of law, the Coroner was entitled to narrow the scope of the inquest in that way. Indeed, most coroners would, I believe, have made a similar decision in these circumstances.”
The Coroner, correctly, did not to stray into an investigation into issues of civil liability and was entitled to decide that issues relating to Zoe’s treatment by the Trust in the months before she died were outside the scope of the inquest and so only formed part of the background facts. Those who had treated Zoe did not need to be called to give evidence or face questions in person because their evidence would not assist the Coroner in answering the question of “how” she died in the narrow way he was approaching it.
Her Ladyship said that this narrow scope had been a proper and lawful exercise of the Coroner’s discretion.
Evidence both ways for suicide
As for addressing suicide, as no final note had been found and her treating clinicians’ view was that Zoe was not planning to kill herself, although she had suicidal ideation and had made attempts (which had not succeeded) in the past. Her family. Had wanted to give evidence that Zoe’s brother had found a suicide note 12-18 months earlier and her mother suggested that Zoe had been in a poor mental state in the weeks before she died and had threatened to take her own life and to succeed this time around.
In circumstances, there was evidence pointing towards and away from suicide conclusion and so the judge considered that the coroner was justified in not returning a suicide conclusion. All agreed Zoe had done the fatal act, but it was a rational and lawful for the coroner not to be persuaded, on balance of probability, that Zoe had intended to kill herself at the time
As the judge pointed out however, the conclusion of “drug-related death” did not exclude the possibility that Zoe took her own life, and it did not exonerate the Trust if matters were to proceed elsewhere by way of civil proceedings. All it meant was that as things stood before the Coroner, he thought it was probable that Zoe had died from an excessive intake of drugs and that was as far as he could go. There was no basis for the Claimant’s suggestion that there was collusion between the Coroner and the Trust to protect the Trust against a finding of suicide.
Limits on questioning
The Coroner had stopped some of the families questions, but he had been entitled to prevent the family from asking questions which he considered inappropriate or irrelevant, including questions on matters outside the scope of the inquest. There was no public law error in the way the Coroner handled this inquest.[1]
However, having noted the family’s frustration at the limited nature of the inquest, the judge observed that it might have been helpful for the Coroner to have taken the opportunity, at the beginning of the inquest, to explain why his inquiry was limited to only looking at how Zoe died and to check that the family understood the process and had received the relevant correspondence and papers; and at the end of the inquest to check that the family understood the conclusion reached and why suicide was rejected.
The family were not aware in advance of the inquest that the Coroner intended to read all the statements that he read. Although that decision, surprising and unwelcome as it may have been to the family, was consistent with the Coroner’s decision on the limited scope of the inquest and it was a decision the Coroner was entitled to make.
Comment
This case is a very important reminder that every inquest, no matter how quick, simple and straightforward it may seem to the Coroner, is a very important process for the bereaved family at its heart.
Here the Coroner held what is sometimes called a “documentary plus” inquest with much of the court time taken up by reading into the record a series of uncontroversial witness statements (under rule 23) and with a single witness giving some live evidence.
Many inquests are brief and quite summary procedures. After all, in many cases that is all that is required to answer the four statutory questions. As Singh LJ said in Morahan:[2]
“An inquest remains an inquisitorial and relatively summary process. It is not a surrogate public inquiry. The range of coroners’ cases that have come before the High Court and Court of Appeal in recent years indicate that those features are being lost in some instances … This has led to lengthy delays in the hearing of inquests, a substantial increase in their length with associated escalation in the cost of involvement in coronial proceedings. These features are undesirable unless necessary to comply with the statutory scheme.”
If Article 2 duties are not engaged it is perfectly acceptable to limit the scope of an inquest to the circumstances immediately surrounding the death. The narrow scope of this particular inquest was reasonably drawn.
But of course, to a family who has lost someone, particularly when there have been shortcomings, albeit non-causative, already accepted by a public body involved in their care, it is of paramount importance to explain the inquest’s purpose and its investigatory scope to them. Sometimes providing the family with a short note or document setting out what does fall within the inquest’s scope, with an explanation of why it is so narrow and what will not be considered, might be helpful in ensuring they understand why such a summary process is being conducted.
One of the Claimant and his family’s particular complaints in this case was that they had insufficient guidance on the inquest process. They were unrepresented and they had expected the Family Liaison Officer from the NHS Trust to be present at the inquest to assist them. She did not come to court and it seems that this Family Liaison Officer subsequently told the family that the Trust had told her that she should not attend.
Although the Coroner believed the family had been emailed the “Short Guide to Coroners’ Services” leaflet they did not recall receiving this. It is also not clear from the judgment whether the Coroner had asked the family in advance of deciding that the only substantive witness would appear online whether they had any views about taking this evidence by video link,[3] nor does it seem that the family were aware before they attended court for the inquest that the remainder of the evidence would be read. The judgment is also silent on whether the family were ever told that they might object to admission of written evidence.[4]
At the heart of this challenge was a mismatch between the family’s expectations of what they might achieve at this inquest and the reality of what the Coroner’s investigation would review, which was a much more limited in its scope.
The Coroner’s decisions were all upheld, but Lady Justice Whipple’s judgment also provides a useful reminder of just how difficult a task it is for unrepresented bereaved to navigate the inquest process without a full explanation of the inquest’s purpose and procedure.
Footnotes
[1] Indeed Rule 19(2) requires a Coroner to disallow any question the Coroner considers to be irrelevant.
[3] Rule 17(3)(a) requires that before giving a direction that a video link will be used to take witness evidence the coroner must have considered in particular any views expressed by any interested person.
[4] See Rule 23(2)(c), although this does not provide any power of veto.