Are presumptions and burdens of proof relevant in inquests? Insanity and unlawful killing considered

R (Bryan) v HM Assistant Coroner for Buckinghamshire [2024] EWHC (Admin) 26 12 January 2024 (judgment here)

This most tragic of cases concerned the loss of two precious and irreplaceable lives when Ms Redmond put herself in the path of a train whilst holding her three year old daughter.

The inevitable conclusion of suicide in Ms Redmond’s inquest was not contested.  But the Coroner did not agree with the position of the Claimant (supported by the paternal side of the child’s family) that the child had been unlawfully killed by her mother.  In a long and detailed narrative conclusion regarding the child’s death the Coroner addressed her mother’s state of mind and determined that this was not an unlawful killing because Ms Redmond had probably been ‘insane’ when she had jumped.

The Claimant challenged both the form and substance of the Coroner’s conclusion, arguing that the Coroner’s finding had impermissibly reversed the presumption of sanity and, in its place, substituted a presumption of insanity.  The challenge failed on all grounds, however, as the Court held that not only was the Coroner entitled to make this finding on the evidence but, given the inquisitorial nature of an inquest, it would be inappropriate to attempt to transpose directly the concepts of a presumption of sanity and the burden of proof as they apply in the context of criminal proceedings to the very different context of inquisitorial coronial proceedings.

Keeping the deceased at the heart of the inquest

Death and taxes: the past, present and future of the coronial service
 A lecture by the Chief Coroner of England and Wales, HHJ Thomas Teague KC, celebrating 10 years post-reform

The Chief Coroner’s speech on the tenth anniversary of the implementation of the Coroners and Justice Act 2009, delivered on 22 November 2023 and available here is essential reading for all Coroners and inquest lawyers.

Aided by a historical perspective going back centuries, it constitutes a full, frank and fearless assessment of the structural deficiencies that remain embedded in the Coronial system. All too often, the system of Coronial investigation in England and Wales is not able to live up to its ideals and values. It remains a ‘forgotten service’. But the speech is a call to action, not just a lament. Its argument for Coronial work as the fulfilment of a ‘posthumous duty to the deceased’ should act as an inspiration for any Coroners, practitioners, and coronial staff perhaps struggling to get through the day given some of the challenges the system faces.

The Coroner is the oldest continuously existing judicial role in England and Wales. The history of the office is entertaining – the venue for many nineteenth-century inquests was the pub – but is not just of antiquarian interest. Whilst the Coroner’s role as a glorified tax collector has been eroded, the modern system is still a residue of its historic origins:

  • The Coronial system remains a means of administering local justice, removed from the national judiciary. A national Coronial service remains an ideal for which there is no apparent political appetite whatsoever. Coronial staff remain formally employed and line managed by local authorities and regional police. As all inquest lawyers know, there remains inconsistency of practice between areas.
  • Whilst all new Coroners must now be lawyers, there is a long history of debate and uncertainty over what professional standards are required of appointed Coroners. The selection of Coroners is still in the hands of local authorities, and not the Judicial Appointments Commission. There is no judicial member on the recruitment panel for Senior Coroners: the Chief Coroner is a silent observer with ‘a veto but no vote’.
  • Inquests, particularly held with juries, have long been a vehicle for anti-establishment and even radical political sentiment. Inquest jurors have consistently conceptualised their role as being one of holding the state to account.

Death Investigation: Coroners and Inquests

A short course for coroners, judges, lawyers and medical professionals
Course director:  Peter Thornton , Visiting Professor at King’s College London (the first Chief Coroner of England and Wales)

In person at King’s College London, Strand Campus, Bush House 

Tuesdays on the following dates: 20, 27 February and 5,12,19 March 2024.

The course will consist of a series of five interactive seminars which will explainand discuss the law and procedure of coroners. It will cover a comprehensiverange of topics from reporting deaths, investigating cases, conducting inquestsand reports to prevent future deaths. 

Participants will be expected to participate in discussion and give shortpresentations. They will consider the importance of the role played by coronersin the administration of justice: Who are they? What do they do? What is thepurpose of their work? How should they do it?

Course fee:


Course accreditation:

CPD points (approval pending) and a King’s certificate of attendance.


Please contact Jennifer Penafiel at or visit

New press guidance on ‘Reporting on Suicide’

IPSO – Reporting on Suicide: Guidance for journalists and editors   1 November 2023 (here)

Open justice must be a crucial principle in any fair and ethical society.   Fair, accurate and contemporaneous media reporting of court proceedings is to be encouraged, and media reporting of matters stated in open court should only be curtailed when strictly necessary. As the earlier IPSO guidance on reporting deaths and inquests (here) recognises, news organisations play an important role in reporting deaths and accidents. But even when done sensitively, this often causes great distress to the families of those involved.

This new guidance, published today from the Independent Press Standards Organisation (press release here), specifically addressing the reporting of death by suicide is to be welcomed as a first step to reducing the risk of damage by such reporting.  As the leading cause of death in people under the age of 35 in the UK the issue of suicide is rightly of interest to the public and press.[1]   However research from around the world shows that media portrayals of suicide, including information published by newspapers and magazines, can influence suicidal behaviour and lead to imitative acts, particularly among vulnerable groups or young people. The research described in the IPSO guidance shows that overly detailed reporting does not just influence the choice of method of a suicide but can lead to additional deaths which would otherwise not have occurred.

The IPSO guidance directed at journalists and editors provides advice on restricting the reporting of unnecessary details of suicide methods (particularly new and emerging methods), and reminds journalists of the importance of reporting inquests accurately and sensitively.

Supplemented by the invaluable advice and skills teaching for journalists to be found in ‘The Suicide Reporting Toolkit’ (here), this new IPSO guidance should assist journalists to ‘make ethical decisions about their storytelling whilst under pressure from various news processes’.  The guidance importantly notes how the media should take particular care when reporting on novel methods, to prevent attention being drawn to a relatively unusual method of suicide.

Review adds teeth to Prevention of Future Death reporting

The recommendations arising from the project led by the Independent Advisory Panel on Deaths in Custody (IAPDC)[1] with support from the Chief Coroner’s Office: ‘ “More than a paper exercise” – Enhancing the impact of Prevention of Future Death Reports’ (here), are to be widely welcomed.  Indeed, it could be seen as a call to government and private agencies to catch up with practice guidance issued by the Chief Coroner in 2020 upon Prevention of Future Deaths reports (‘PFDs’) (here).

PFDs are not a punishment

Coroner’s have been saying for years that, “PFDs are not intended as a punishment; they are made for the benefit of the public”.  However, the IAPDC found a culture of resistance to PFDs has developed whereby institutions consider such reports are to be avoided at all costs rather than being seen as a tool for needed reform of the services protecting all of our lives.  The report recommends government agencies view these reports “an opportunity for organisations to improve, share good practice, and ultimately prevent custodial deaths – not as criticism to be avoided at all costs”.