R(Bailey) v HM Senior Coroner for East London [2025] EWHC 1637 (Admin) 30 June 2025 (judgment here)
Once the investigative obligation under Article 2 ECHR is engaged an inquest will most often be the means by which the state will satisfy the procedural obligations that follow. However in situations where the inquest has been suspended due to a homicide trial then the Coroner considering whether to resume an inquest will always need to consider whether other investigative procedures of the state that have already been conducted have, collectively, satisfied the requirements of the procedural obligation.
The principles of law involved are now relatively clear. The Art.2 procedural obligation requires a state, of its own motion, to carry out an investigation into a death that: (i) has a sufficient element of public scrutiny of the investigation or its results; (ii) is conducted by a tribunal that is independent of the state agents who may bear some responsibility for the death; (iii) allows the relatives of the deceased to play an appropriate part in it; and (iv) is prompt and effective.
The more difficult question is how to apply that law in practice, when each case must be looked at on its own unique facts. As readers of this blog will know, in Silvera the pre-inquest investigations had not been enough. In Grice there had already been sufficient independent examination of state shortcomings for the Art.2 obligations to have been satisfied without an inquest.
This recent High Court decision adds some more colour to the complex picture. There is not really any new law here, but there is a helpful insight into how the court might approach the issue when a Coroner declines to hold an Art.2 inquest, believing enough has already been done.
Background
Jaden Moodie, who had become embroiled with ‘county lines’ drugs gangs, had been riding a moped when he was rammed by a car. Those inside the car then got out and fatally stabbed him. Jaden, was only 14 years old.
At a contested criminal trial Ayoub Majdouline was convicted of Jaden’s murder and sentenced to life imprisonment. An independent Serious Case Review (‘SCR’) commissioned by the local Safeguarding Children’s Board (published here) identified a number of shortcomings on the part of the numerous public bodies that had been involved with Jaden to protect him from criminal exploitation.
The SCR report set out a detailed history of Jaden’s and his family’s contact with various public services. It contained criticisms of failures and shortcomings on the part of the local authorities and police forces involved with the family in Nottinghamshire, London, and Dorset. It explained the ways in which they had failed to work together effectively and made several recommendations. Investigations were also conducted into the Claimant’s complaints of alleged failings by the Nottinghamshire and Metropolitan police forces – although the IOPC passed the complaint to the Metropolitan Police to investigate itself. The resultant report[1] upheld two of the Claimant’s complaints but rejected the remaining five complaints.
An inquest had been opened but suspended pending the homicide trial. The Senior Coroner accepted that the State’s investigative obligation under Article 2 ECHR was engaged by the circumstances of Jaden’s death, but he considered that the investigative processes so far conducted had satisfied that procedural obligation. He therefore declined to resume the inquest on the grounds that he did not have sufficient reason to do so. In the Senior Coroner’s view the existing investigations had covered all the ground (and even more) that an inquest might be expected to cover.
Jaden’s mother challenged that decision: it was her case that the Art.2 obligation to investigate had not yet been discharged.
The grounds for Judicial Review
The Claimant relied upon three grounds of challenge: (i) the decision not to resume the inquest gave rise to a breach of the procedural obligation under Art.2 ECHR; (ii) the Coroner’s conclusion not to resume the inquest rested on two errors of law as to the likely utility of the resumed inquest and (iii) the decision was contrary to a common law duty on the coroner to investigate Jaden’s death.
The Art.2 procedural obligation
It was common ground that the Art.2 procedural obligation requires a state, of its own motion, to carry out an investigation into a death that has the following features (sometimes known as the Jordan criteria): (i) It must have a sufficient element of public scrutiny of the investigation or its results. (ii) It must be conducted by a tribunal that is independent of the state agents who may bear some responsibility for the death. (iii) The relatives of the deceased must be able to play an appropriate part in it. (iv) It must be prompt and effective.
Mr Justice Swift agreed with the Coroner that the investigations to date, particularly the SCR, had already discharged that burden in Jaden’s case.
The judge described the SCR report as a “thorough and thoughtful consideration of all relevant matters.” He went on to say that “the SCR report is a highly impressive piece of work that should provide valuable assistance to all public authorities concerned. By identifying it very clearly things they did and things they failed to do the SCR report ought both to promote accountability for what happened and to provide valuable guidance to those public authorities as regard their future conduct.”
Although the Claimant suggested more detailed review might be conducted by an inquest the judge was not persuaded. Swift J. pointed out that “considering a document such as this SCR report it will always be possible to point to further questions that could have been considered or further detail that could have been looked for. But that is not the test of whether the investigation that has been undertaken meets the requirement arising under article 2.”
The judge considered that the SCR report, as written, evidences an effective investigation of the actions and omissions of the responsible public authorities.
The Claimant wanted an investigation into what might have been done differently to safeguard Jaden, but as the judge pointed out the purpose of a coronial investigation was to establish the facts regarding what did happen and not to look at what might have happened. The focus of an inquest would be on what actually took place, and the SCR established this already.
What is appropriate to meet the objectives of Art.2 is not fixed
The Claimant argued that the SCR process was inadequate because it lacked the power to compel witnesses; that the investigation was not conducted in public, so it did not ensure accountability; and that she was insufficiently involved with the investigation process. But as the judge noted what is appropriate to meet the objectives of Art.2 is not fixed. There was no in principle reason why an investigation of the kind conducted through this SCR was incapable of satisfying the Art.2 investigative duty. Art.2 did not require that an investigation must be conducted through public hearings. In terms of the public interests that the ECHR serves to protect, public scrutiny by way of the publication of the SCR report was sufficient.
As to involvement of the bereaved, the judge cited the numerous attempts to engage the Claimant who had rebuffed the many offers to meet her made by the SCR reviewer. The judge said that “real and substantial” opportunities to participate were available to the Claimant from the outset of the SCR investigation Her lack of participation in the SCR had been her choice. In any event the requirement for the family of the deceased to be involved in an investigation to the extent necessary to safeguard their interests did not mean that the investigating authorities must satisfy every request for a particular step to be taken in the investigation.
The Coroner was entitled to find that the Art.2 procedural obligations had been met by the investigative processes already conducted, and so an inquest was not required on this ground.
Errors of law?
The Claimant criticised the coroner having said in his ruling that the “primary” inquest conclusion would need to be consistent with the criminal finding of unlawful killing. The Claimant suggested that the Coroner had thereby excluded the possibility of a narrative conclusion.
The judge did not agree with this construction of the coroner’s ruling. Swift J noted that the suggested distinction between “short-form” and “narrative” conclusions that was the premise of this submission was a distinction without a difference. There was no material difference between a conclusion expressed using any of the terms listed in Note (i) on Form 2 (the Record of Inquest form) and one that is in the “brief narrative” form anticipated by Note (ii) of that form. Each is as intended to be descriptive: to describe the outcome of the inquest. A conclusion of “unlawful killing” could be given either by simply using those two words or through a longer narrative to the same effect. The point being made by the Coroner in his reasons was that the conclusion reached at an inquest, however expressed, would have to be consistent with the conclusion of unlawful killing given the outcome of the criminal trial. But the Coroner did not disregard the possibility that the conclusion at any resumed inquest might take the form of a narrative.
The Claimant also took issue with the Coroner’s reasoning that the possibility of him issuing a regulation 28 report was an insufficient reason to resume an inquest because such reports are “toothless”. But as, the judge noted, if the whole sentence were read, it was clear that the Coroner’s use of this word disclosed no material misdirection or error of law. It was correct that the contents of a reg. 28 report are not prescriptive. The Coroner’s turn of phrase was, he said, “colourful but not wrong”.
No Common Law duty to investigate
Finally, although a common law duty to hold an inquest was initially argued for, the Claimant appears to have abandoned her pleaded case on this issue.
The Coroner submitted that there was no freestanding common law duty to conduct an inquest, and that the only obligation upon him to hold an inquest was the statutory one arising under CJA 2009. The Claimant accepted that the Coroner’s only obligation to investigate was contained in the 2009 Act. As the judge noted “there is no separate common law source of either power or obligation.”
Adopting an alternative position, the Claimant contended that the decision not to resume the inquest was made by the Coroner without first having regard to some relevant considerations related to the common law purpose of an inquest. That is: (i) the public interest in holding and inquest; (ii) the purpose pursued by section 5 of the 2009 Act; and (ii) that an inquest can serve to allay any public concern arising from a death.
The judge was not persuaded as in his view it was readily apparent from the Coroner’s decision, read in the round, that he took these matters into account since each was integral to the notion of the investigation required under the provisions of the 2009 Act. The challenge therefore failed.
Commentary
This case reaffirms the law, set in a particular factual context. In doing so it provides a helpful reminder that inquests are not surrogate public inquiries nor are they civil trials. The factual inquiry at an inquest should be focussed upon seeking out and recording what did happen. It was never intended that a Coroner or inquest jury should decide what should have happened, as the Claimant seemed to want to be explored here.
This SCR had been a particularly impressive and detailed review, the facts of what occurred in Jaden’s case were all recorded in a document published five years ago in which shortcomings were identified and recommendations made. It is hard to see how an inquest might have improved on the matters reviewed by the very experienced and wholly independent SCR author.
Article 2 does not prescribe the form of state investigation that must take place. Different signatories to the Convention will adopt very different processes. All that truly matters is that the review by the state is independent, prompt and effective, with relatives able to play an appropriate part (if they choose to do so) and that the investigation or its results are sufficiently public. In Jaden’s case the Senior Coroner had thought this had all been achieved already. The judge agreed.
Bridget Dolan KC of Serjeants’ Inn Chambers advised and represented the Senior Coroner in this claim.
UK Inquest law blog is grateful to the Senior Coroner who has agreed that his initial ruling can be made available to blog readers here
Footnotes
[1] Which followed a re-investigation by the Met police conducted at the IOPC’s request