Inquests often reveal matters that are of concern but which are unlikely to give rise to a risk of future deaths and so fall outside the reg. 28 “Report on Action to Prevent Future Deaths” provisions (the ‘PFD report’). Yet it is often overlooked that where the duty to make a PFD report does not arise, the coroner still has another tool in their public health kit and may nevertheless draw attention to a matter of concern arising during the investigation by writing a letter expressing that concern to the relevant person or organisation who can act upon it.
Known as a ‘Paragraph 37 Letter’ such a step is proposed and approved by the Chief Coroner at paragraph 37 of his Guidance No. 5 (Reports to Prevent Future Deaths); yet it is only rarely used.
Ewing v Cardiff and Newport Crown Court  EWHC 183 (Admin)
Bereaved friends and other members of the public often take notes of the evidence given in Coroner’s Courts. Whilst Coroners can dictate much of the practice and procedure within their own courts, the recent case of Ewing in the criminal jurisdiction has clarified that it is only in very limited circumstances that restrictions should be placed on observers taking notes in public hearings and that no express permission to take notes is required.
“Although the Court may, for good reason, withdraw the liberty to take notes, the default position is that anyone who attends a public hearing is free to take notes.”
R (Speck) v HM Coroner for York & (1) NHS England (2) MEDACS (Interested Parties)  EWHC 16
In a case which serves as a reminder that an inquest should not be seen as a substitute for a public inquiry, the Admin. Court has held that, where a coroner conducting an Art 2 inquest decides that a factor could not even arguably be said to have made any real contribution to the death, then there is no discretion, or indeed power, to investigate that issue. Coroners’ investigatory powers arise from their statutory duty under the Coroners and Justice Act 2009 s.5 and their discretion is limited to investigating only those factors that might arguably have contributed to a death.
It would be “wrong in principle” to “go into issues of policy and resources with which an inquest should not be concerned”.
Today the Chief Coroner published new guidance on Pre-Inquest Review Hearings (PIRHs) and revised guidance on coroner’s conclusions (Guidance No.17 (as amended)).
The newly published guidance on PIRHs reaffirms the guidance already provided in the cases of: Brown v HM Coroner for Norfolk  Inquest Law Reports 91, Shafi v HM Coroner East London  Inquest Law Reports 154 and Fullick v HM Coroner for Inner London North  EWHC 3522. It encourages: PIRHs in complex cases, circulating agendas in advance and, if relevant, advance notification of the coroner’s provisional views on the respective issues.
The amended guidance on conclusions addresses the sometimes hotly contested questions of (1) what, if any, difference remains in law between a non-Article 2 v. Article 2 conclusion (2) whether a non-Article 2 conclusion is permitted in law to be judgmental and (3) is the coroner’s power in an Article 2 inquest to leave to a jury, for the purposes of a narrative conclusion, possible circumstances restricted to only where those findings will assist the coroner in a PFD report?
Flower v HM Coroner for Devon, Plymouth, Torbay and South Devon  EWHC 3666 (Admin) 16.12.2015
In a welcome clarification of the extent of a Coroner’s powers to re-open an inquest after having decided not do so, the Divisional Court has confirmed that, where an investigation has been suspended pending criminal proceedings, and a Coroner has determined that it should not be re-opened, the Coroner is not functus officio and so can revisit and change their own decision. Indeed the High Court has no jurisdiction to order an inquest under s13(1)(b) Coroners Act 1988 in such circumstances.
There had been no inquest and hence there were no inquest findings to quash.