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:

£950

Course accreditation:

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

Application:

Please contact Jennifer Penafiel at Law-ppee@kcl.ac.uk or visit https://www.kcl.ac.uk/short-courses/coroners-inquests

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”.

Accessing protected AIB material in a criminal trial

 ORR and Dorris v Secretary of State for Transport [2023] EWCR 1 (judgment here)

This judgment, that was held back until the completion of a criminal trial, highlights again the thorny issue of the disclosure into subsequent legal proceedings of ‘protected material’ that has been collected during an independent Accident Investigation Branch’s (‘AIB’) investigation.

Limited and proportionate disclosure of protected Rail Accident Investigation Branch (‘RAIB’) material was ordered for this criminal trial to permit the relevant experts to comply with their oaths to tell the jury the whole truth, and not be inhibited in doing so.  The disclosure was extremely circumscribed and limited to that strictly necessary for a fair trial.

Notably this prosecution came after the inquest into the seven deaths in the Croydon ‘Sandilands’ tram crash and as such the decision does not make any inroads into the position in coroner’s courts, where deference to the AIB as the body with the greatest expertise will continue to mean that a coroner will generally not be permitted access to AIB material to investigate the cause of a fatal incident for themself.

Adopting Accident Investigation Branch reports and the requirement to conduct Inquests fairly

R(Mid and West Wales Fire & Rescue Service) v Senior Coroner for Pembrokeshire & Carmarthenshire and Marine Accident Investigation Branch [2023] EWHC 1669 (Admin) 12.7.23 (judgment here)

 

The High Court’s Norfolk[1] decision has sat uneasily with some in the coronial law community. Although coroners have a statutory duty to investigate a cause of death, the effect of the Norfolk case is that if an investigation into a fatal incident has been undertaken by one of the UK’s three Accident Investigation Branches (‘AIBs’)[2] the coroner is obliged to accept, wholesale, the conclusions of that earlier AIB investigation.

As the High Court emphasised in Norfolk a coroner will comply sufficiently with their statutory duties by treating the findings and conclusions of the report of an independent AIB as the evidence as to the cause of a fatal accident.

The thorny issue of whether this is an obiter statement or part of the ratio decidendi of the decision has, however, continued to be debated.  In the Shoreham Aircrash ‘Sussex’ case [3] the Senior Coroner neatly sidestepped the argument by saying that, even if this part of the judgment was merely obiter, she was still going to follow it, particularly as it was, on any analysis, strong guidance by a court that included the Lord Chief Justice (‘LCJ’).   However, that issue has now been put beyond question, having been fully argued before the court in this most recent MAIB case.

Mr Justice Eyre has now held that the determination in Norfolk that, as a matter of principle, there could be no public interest in the duplication of investigations, was a necessary step in the court’s reasoning and so was ‘clearly’ part of the ratio decidendi of Singh J’s Norfolk judgment (with which the LCJ agreed).

As a consequence, the main challenge to the Norfolk decision raised in the present case: that it was unfair to put the MAIB report before the jury and not allow further questioning of it, was dismissed.  Furthermore, an additional multi-pronged attack on the MAIB investigation (as being incomplete, flawed or deficient) and on the coroner’s ruling (as being inadequate and unlawful) also failed on every ground.