The High Court’s refusal of permission in this recent case provides a useful reminder of how carefully coronial language is policed—and what room remains for evaluative description short of liability.
The case arose from a tragic incident in January 2020, when a spectator at youth rugby matches, was struck on the head by a ball during a warm-up. Because she suffered from aplastic anaemia, the injury had catastrophic consequences and she later died. Following an inquest, the Senior Coroner recorded a narrative conclusion: “Accidental death contributed to by poor supervision and spectator safety management.”
The Rugby Clubs sought permission for judicial review, focusing in particular on the use of the word “poor”. Their primary submission was that this adjective crossed the statutory boundary in section 10(2) of the Coroners and Justice Act 2009, because – so they argued – it appeared to determine civil liability.
The Claimants’ Argument: “Poor” Implies a Standard
The argument was not that the Coroner had explicitly made a finding of negligence, but that the word “poor” is inherently judgmental. It invites comparison with an objective standard: at minimum suggesting conduct falling below what is acceptable or reasonable. On that basis, they argued that the conclusion arguably strayed into the territory of civil fault.
The claimants relied on established guidance and authority emphasising that narrative conclusions in non-Article 2 inquests should be neutral and factual. The Chief Coroner’s Guidance warns against terms that suggest breach of duty, such as “negligence” or “careless” . The submission was that “poor” operates in a similar way, even if expressed less formally.
The Coroner’s Position: Evaluation Without Liability
The Coroner’s response, endorsed by the court, drew a distinction between evaluative language and legal conclusions. Describing conduct as “poor” does not, without more, import the elements of a civil claim, ie duty, breach, and causation in the legal sense.
On this view, the conclusion remained within the Coroner’s statutory function: identifying factors that more than minimally contributed to the death. It did not purport to determine liability or resolve any civil standard of care.
The Court’s Approach: Ordinary Language Matters
Both Jefford J (on the papers) and Kimblin J (on renewal) rejected the challenge. The key reasoning was pragmatic and rooted in ordinary language:
- The statutory prohibition is concerned with appearance of determining liability, but not every evaluative word crosses that threshold.
- “Poor” is not synonymous with “negligent”.
- Conduct can fairly be described as poor without implying a breach of the legal standard of reasonable care.
The court therefore held that it was not even arguable that the wording infringed section 10(2).
- The boundary is contextual, not semantic.
The question is not whether language is evaluative, but whether it appears to determine civil liability. Words must be assessed in context, not in isolation. - There remains space for measured criticism.
Coroners are not confined to purely mechanical descriptions. They may identify deficiencies in systems or conduct, provided they do not express conclusions in terms that equate to legal fault. - Drafting challenges persist.
The distinction between permissible evaluation and impermissible attribution of liability is fine. Terms like “negligent” or “breach of duty” remain clearly prohibited; others, like “poor”, may be acceptable depending on context.
The case illustrates the careful balance required in coronial conclusions. Inquests must explain how a death occurred, sometimes including contributing factors, but must avoid trespassing into the determination of liability reserved for civil proceedings.
“Poor supervision” was held to fall on the permissible side of that line. It conveyed a finding about the quality of arrangements without purporting to decide whether those responsible were legally at fault.
For lawyers advising on inquests (or challenges to them) the decision is a reminder that not every critical adjective will support a public law claim. The statutory prohibition is strict, but not absolute: it excludes findings of liability, not all forms of evaluative judgment.
Scott Matthewson and Bridget Dolan KC of Serjeants’ Inn Chambers advised and represented the Senior Coroner in this case