Senior Coroner for Northumberland v Assistant Coroner for Northumberland [2026] EWHC (Admin) (extempore ruling) 17 June 2026.
Things can go wrong in inquests. Slip ups and misspeaks are just part of being human. Yet, frustratingly for a coroner, if they want to do the right thing and quickly correct their own innocent mis-statement they will not be able to put things right themselves if the ROI has already been signed making them functus officio (ie their authority to take further steps has expired).
It is then good to learn that what has become known to some as the “Shipsey fix” seems to be working out behind the scenes, even if it is not as yet producing published judgments that might let everyone learn how to use it. Your blogger only came across the Shipsey fix in action yesterday when a fortuitous listing meant the Divisional Court had listed this case concerning the Northumberland Coroner for an unattended ‘pronouncement’ immediately before her own hearing.
In this Northumberland case an error in the Coroner’s determinations had come to light four days after an inquest concluded. All involved agreed that the two rogue words ‘family and’ needed to be red lined and struck out from box 3 of the ROI. Happily, the case of Shipsey made clear the High Court has the power to offer this remedy within a s.13 application without the need for a fresh inquest. The Divisional Court was very happy to make that pronouncement yesterday, based on the papers and without the need for any parties’ attendance the only drawback is that it took 18 months for that to actually happen. Surely here has to be a better way?
The facts
The deceased who was 78 years old had driven his car into wall when not wearing a seatbelt and sustained fatal injuries. Police visited his house and found he had left a note and set of contact numbers. Recently, since his wife had died, he had expressed suicidal intent to health professionals. However, he had not given his consent for this information to be shared with his family, nor had he expressed any suicidal ideation to family members.
The inquest held on 20 December 2024 was a “Rule 23 inquest” determined on the basis of the documents alone with no witness in attendance. The documents included a statement from the deceased’s brother who said he had been unaware of his suicidality.
The Assistant Coroner unsurprisingly concluded that the death was from suicide. The narrative in in box 3 of the ROI included the phrase that the deceased had “expressed the intention to take his life to family and professionals….”.
When the brother learned of the Assistant Coroner’s findings four days later, on 24 December 2024, he made it clear that he had not known of the deceased’s intention to take his own life. The Assistant Coroner agreed that there was no evidence of such knowledge and that including the words ‘family and’ in Box 3 had been an error. But as the Coroner was now functus officio it was too late to just amend the ROI: only a Judicial Review claim or an application under s.13 Coroners Act 1988 might achieve this.
No one wanted a fresh inquest here, the family only wanted the public record to accurately reflect the truth. A s.13 application was therefore made by the Senior Coroner (with the Assistant Coroner as the defendant) seeking to quash just those two offending words: “family and”.
This approach was in line with the ‘fix’ that had first been endorsed by the High Court in March last year in Shipsey v Senior Coroner Worcestershire [2025] EWHC 605 (Admin) (see our blog here) when it was held that the High Court had the power under section 13(2)(c) Coroners Act 1988 to amend a Record of Inquest by merely quashing, removing or ‘red-lining’ offending words in a determination, albeit that s.13 does not permit the court to get out its best red pen and start adding its own words.
The ruling
Lady Justice Whipple, qave an extempore ruling on behalf of the Court. She considered that there were two questions for the Court to consider in this case: (i) did this case meets threshold under s.13(1)(b) Coroners Act 1988 and, if met; (ii) how could the court intervene.
On the first question Whipple LJ was satisfied there was no evidence of relevant family knowledge and readily accepted that the words ‘family and’ in box 3 was an error that amounted, in this case, to an ‘irregularity of proceedings’ or which fell within the catch all of ‘otherwise’ in s.13 (1). It was clear that the error rendered box 3 incorrect and was serious enough to cause the bereaved family understandable anguish. Her ladyship found that the statutory threshold of it being ‘necessary and desirable’ to act was met.
On the second question of what relief to give, Whipple LJ could see no reason to depart from view expressed in Shipsey that s.13(2) Coroners Act 1988 empowered the High Court to quash just part of a coroner’s determination without quashing the entire inquest.
Striking through the words ‘family and’ would cure the defect and the record would then be accurate, thereby achieving the outcome sought by all. The necessary order was therefore pronounced.
Comment
This case provides judicial confirmation (if such were needed) of the availability of the ‘Shipsey fix’ or red lining solution under s.13. this can be a really useful mechanism to put things right where there has been something has been wrongly recorded on the ROI but there is no need to to put everyone through the full inquest again.
But whilst this is a simple remedy, it is not a very quick one. The inquest was held on 20 December 2024, the error was drawn to the coroner’s attention just 4 days later. It was not explained within the pronouncement decision how it came to be almost 18 months later before the Divisional Court were in the position to make this unopposed order with the consent of all parties on 17 June 2026.[1]
Given all parties consented there was no need to hear any legal argument or list the hearing for any party or their counsel’s convenience. The delay therefore looks depressingly administrative as the case passed slowly through the hands of the Coroner, the Attorney General (seeking his fiat) and then the High Court.
It led your blogger to wonder whether such claims might still more efficiently brought by Judicial Review which at least avoids any delay that might be caused by having to apply to the Attorney General’s office for a fiat (see our blog last year on the thorny issue of delays occasioned by the fiat process here).
When a compromise order is offered in a Judicial Review claim the question of permission becomes redundant, if errors are spotted within three months of the initial decision the matter may be dealt with much more quickly by the Admin Court correcting the error by agreement within Judicial Review proceedings.[2] Whilst the s.13 ‘Shipsey fix’ has many advantages the speed of justice for the bereaved does not, on present evidence, appear to be its strongest suit.
[1] Unlike Judicial Review there is no process to compromise a s.13 application by means of a ‘consent order’ the power is that of the High Court and, as such, a formal decision must be made by a Divisional Court even where, as here, all parties agree.
[2] See R(Hunter) v HMAC Durham and Darlington [2024] EWHC 1275 for an example – although even in that case 10 months passed between the initial letter before claim to the final order in the judicial review claim..