You should read the Record of Inquest as a whole

R (Bilski) v Her Majesty’s Coroner for Inner West London [2021] EWHC 3339 (Admin)

It was perhaps more in hope than expectation that the Claimant sought an oral permission hearing in this judicial review claim, where the main issue in contention was the adequacy of a single box within the Record of Inquest form (‘ROI’). It seemed there could be no question that the necessary statutory determinations had been made by the coroner following an inquest. Furthermore, those determinations had been fully recorded on the ROI. The Claimant’s grievance was that the coroner’s findings appeared in the wrong part of the ROI form. Two High Court judges in turn found that this contention was simply unarguable. It will not justify a fresh inquest just because a determination has not been written in a particular box on the ROI.


The header to box 3 of the ROI form does of course indicate this is a place to record: “How, when and where…the deceased came by his or her death”. However, at the conclusion of Ms Bilski’s inquest the coroner had completed box 3[1] of the ROI form by setting out ‘when’ and ‘where’ the deceased had died, but had not covered ‘how’ Ms Bilski died within that particular section. Nevertheless, a quick glance at box 2 above (the cause of death) or box 4 below (the conclusion) made it abundantly clear that the coroner had found that the natural cause of Ms Bilski’s death had been a sub-arachnoid haemorrhage.

The Claimant was, however, sufficiently unsatisfied with the inquest to try to argue that the ROI was ‘fundamentally defective’ such as to make the entire Record of Inquest unlawful, because it omitted any explanation of ‘how’ the deceased died in box 3.

Neither Williams J (who refused permission on the papers) nor Whipple J (who refused again at an oral permission hearing) were impressed: of course, it would have been better if box 3 had cross-referred to box 4, but there was no lack of clarity as to how the deceased came by her death, it was readily discernible from reading the whole of the ROI form. As Whipple J put it “all the information which informs how this deceased died is undoubtedly on the Record of Inquisition.” There was no addition to box 3 which would make that record any clearer or fuller.

It seems that perhaps the real complaint was that the Claimant wanted the coroner to have captured more of the deceased’s preceding medical history in box 3. The facts were that a month before her death the deceased had attended hospital where an aneurysm had been identified. But this event was part of the background facts only, her earlier aneurysm did not explain “how” the deceased came by her death for the purposes of this inquest and so there had been no need to record it. As Whipple J emphasised, this was a ‘Jamieson’ inquest and so the questions of how, where and when the deceased came by her death were narrow, with the focus on the immediate circumstances on the day of her death.

Given the narrow scope of the inquest, the Claimant’s second ground of challenge – that more specialised medical expert evidence regarding the earlier aneurysm had been required – was also unarguable. The coroner had heard from a doctor with sufficient expertise in sub-arachnoid haemorrhages to elucidate the cause of death. Therefore, the coroner had been correct to refuse the request of the claimant to adjourn the inquest in order that a specialist vascular neuro-surgeon could be instructed to deal in more detail with the earlier aneurysm. As the aneurysm was only a background matter there was no reason for the coroner to adjourn to get a further expert report about it. She had all the experts that she needed to deal with this tragic case of a sub-arachnoid haemorrhage. Permission was therefore refused.


This case is welcome clarification that one should not read the ROI in a piecemeal fashion. Everything written upon it represents the findings from the inquest and they should be taken as a whole.  Happily, the ongoing debate about whether a narrative conclusion need appear in box 3 or box 4 is clearly now rather stale. So long as the ‘how, when and where’ and any circumstances that Art 2 requires are covered somewhere on the form it will be good enough.

In the civil courts, the rules provide[2] that a court ‘may at any time correct an accidental slip or omission in a judgment or order’. Whilst this ‘slip rule’ cannot be used to make substantive changes or to correct errors of law, it can be applied to give effect to the court’s first thoughts or intentions at the time of making the order. Sadly, there is no equivalent of this ‘slip rule’ in the coronial jurisdiction when a ROI has been completed and signed. Had it been so, then when the letter before action arrived on her desk this coroner might have, for absolute clarity, simply added ‘see boxes 2 and 4’ to box 3 of the record of inquest. Nevertheless, even that is no longer necessary – as this case makes clear basic common sense should prevail – one should read the whole of the ROI form when looking for answers to the statutory questions, and not just read part of it in isolation.



[1] The term Box 3 was use in the judgment – although the word ‘box’ is perhaps a misleading hangover from a time when the form was actually printed with boxes.  It now only has one ‘box’ to complete under section 5 where the registration particulars are to be completed.

[2] See CPR 40.12