HM Senior Coroner for South London v Alexei [2025] EWHC 2768 (Admin), 7 October 2025, judgment here
The question of which evidence to call at an inquest is a matter for the coroner alone. The coroner should call sufficient evidence and conduct a sufficient inquiry to answer the statutory questions. However, the Courts have repeatedly emphasised the wide area of judgment that a coroner enjoys in deciding who to call to give evidence.[1] It is a matter of coronial discretion whether their investigation has uncovered sufficient evidence on a key point to allow for an adequate inquest to then follow. ‘Sufficient’ is not a particularly high standard, an adequate investigation will be good enough. The decision regarding whether further evidence should be sought will often be made bearing in mind a number of factors, including: (i) the rule 8 requirement to complete an inquest within six months; and (ii) how likely it is that any additional evidence that might be obtained will contradict the evidence that is already available.
However where a coroner goes ahead on the basis of only a provisional or preliminary medical expert report there is always a risk that the expert’s final opinion might differ. Unfortunately for the coroner holding this inquest, that is precisely what occurred.
The facts
Mr Robinson was found dead at home in January 2020. Sadly he was in a state of decomposition such that he had to be identified by an odontology expert. A provisional post mortem report was provided that did not establish any cause of death and toxicology samples were also unable to provide a cause.
Some months later the pathologist had not completed the final post mortem report because he was himself off sick. The coroner decided nevertheless to proceed to an inquest in November 2020, and having expressed the view that she was content that on the available evidence the medical cause of death was “unascertained” recorded this, recognising that if further evidence became available, then this matter would be revisited. Unfortunately, that is exactly what happened.
In due course, the pathologist returned to work and completed his post mortem report. He now gave his opinion that the death was due to natural causes recording these as being: 1(a) ischemic heart disease; 1(b) coronary artery atheroma; and 2: right bronchopneumonia chronic obstructive airways disease.
By this point of course the only way to formally recognise that a natural cause of death had now been established was to hold a fresh inquest. A draft consent order confirmed the agreement of the deceased’s sister (unusually cast as the ‘defendant’[2]) to a fresh inquest being held and a fiat was soon obtained from the Solicitor General so that the required s.13 application might be made by the Coroner.
The decision
The very brief judgment makes it clear this was not a decision that troubled the Divisional Court bench for long. The test to apply was that from the Hillsborough case[3] which established that “it is elementary that the emergence of fresh evidence which may reasonably lead to the conclusion that the substantial truth about how an individual met his death was not revealed at the first inquest, will normally make it both desirable and necessary in the interests of justice for a fresh inquest to be ordered”
A determination on the Record of Inquest was obviously incorrect in the light of the revised medical opinion, and so it would clearly be in the interests of justice for a fresh inquest to be held. Accordingly, a fresh inquest was ordered.
Commentary
The judgment does not explain how over four years passed between the first inquest being held and this new pathology evidence prompting the request for a fresh inquest. However, it is encouraging to see that there was no hold up at the Attorney General’s office (who apparently dealt with the fiat application in ten weeks).[4] It was then a further six months before what was always going to be quite a brief Divisional Court hearing was listed. All these different cogs of justice needing to turn will unfortunately have left Mr Robinson’s sister with a rather a long wait for the official record of her brother’s death to be put straight via a second inquest.
Obtaining the fresh inquest will also have taken up staff time in the Attorney General’s Office and the Administrative Court Office. It then required a Court of Appeal judge and a High Court judge to find court time to sit and hear the case. Counsel was instructed (through solicitors) to attend and put the case before the court, all of this at public expense.
The s.13 requirement is one of the few sections still in force from the Coroners Act of 1988. Is it not now time to come up with a quicker, cheaper and simpler process when it is a Senior Coroner who wishes to overturn their own jurisdiction’s inquest?
[1] R (Mack) v HM Coroner for Birmingham and Solihull [2011] EWCA Civ 712 at §9
[2] although the Senior Coroner was applying to overturn an inquest that had been held by her own Assistant Coroner.
[3] In HM Attorney General v HM Coroner of South Yorkshire (West) & Anr [2012] EWHC 3783 (Admin) ; [2012] Inq. LR 143 at [10]
[4] The draft consent order provided to the Court has been dated 23 November 2024 and the fiat was issued on 5 February 2025.