Inquests and Inquiries Update – April - May 2024

Report of the Chief Coroner to the Lord Chancellor: Annual Report for 2023 published

The report sets out a number of recommendations to improve the coroner’s service including:

• Amending the Coroners Act 1988 s.13 to enable the High Court to amend the Record of Inquest without ordering a fresh investigation when it quashes an inquest, and to enable a coroner to apply to the High Court to quash an inquest and hold a fresh investigation without the preliminary need to seek authority from the Attorney General to make such an application;
• Amending s.24 of the 2009 Act to define the division of responsibility between the local policing body and the relevant local authority for the coroner area;
• Amending the relevant provisions to extend the ability to conduct inquests in writing to treasure inquests;
• Amendments to make it a statutory requirement for coroners to take the judicial oath; and,
• Enabling retired circuit judges to be nominated to conduct judge-led inquests.

The full report is available here.

His Majesty’s Senior Coroner for Sefton, Knowsley and St Helens v Kay [2024] 5 WLUK 233

The coroner applied under s.13 of the Coroners Act 1988 for a previous inquest to be quashed and for a fresh inquest into the deceased’s death to be ordered.

The deceased had been found dead in her bed in October 2020 with empty packets of prescription medication next to her. An inquest hearing took place in February 2021 and the coroner recorded the cause of death as bronchopneumonia and mixed drug toxicity. In March 2021, the coroner was made aware that suicide notes written by the deceased had been discovered and the deceased’s medical records disclosed a history of suicidal intentions including intentional overdosing. The coroner had not been aware of this information at the time of the inquest.

The Divisional Court confirmed that the proper approach to s.13 application was as set out in R. (on the application of Sutovic) v HM Coroner for Northern District of Greater London [2006] EWHC 1095 (Admin) and emphasised that here the possibility of a different verdict, the need to investigate matters raised by new evidence and shortcomings in the original inquest were of central importance.

The Court also noted that it was not essential that a different determination was probable, but the likelihood of it was a factor (Attorney General v HM Coroner for South Yorkshire (West) [2012] EWHC 3783 (Admin) applied). The factors to be considered in determining whether a fresh inquest should be held included: new evidence; the possibility of a different decision; the family’s wishes; the time elapsed since the original inquest; and the delay in applying for a fresh inquest.

The Court held that the original inquest should be quashed, and a fresh inquest ordered and the application under s.13 was granted.

Death Certification Reform

The Medical Certificate of Cause of Death Regulations 2024, the Medical Examiners (England) Regulations 2024, the National Medical Examiner (Additional Functions) Regulations 2024 and the Medical Examiners (Wales) Regulations 2024 form part of the wider reform of the death certification process which will change the way in which causes of death are scrutinised and certified in England and Wales.

These regulations, which come into force on 9 September 2024, introduce a statutory medical examiner system which means that all deaths not investigated by a coroner will be reviewed by medical examiners. Medical examiners are senior medical doctors that independently scrutinise the causes of death.

More details here.

Joint Committee on Human Rights report published: “Human rights and the proposal for a "Hillsborough Law"”

A Joint Committee on Human Rights report has called on the Government to go further in improving how the state responds to major tragedies. The Report noted that institutional defensiveness appears to remain a problem for public authorities, particularly when they are involved in public inquiries and inquests. This hinders efforts to establish the truth when things go wrong, and stands in the way of fulfilling the State’s investigative obligations under Article 2 and Article 3 ECHR.

The Report argues that a general statutory duty of candour would help to ensure that the priority for public bodies is to establish what has gone wrong and needs to be changed in order to prevent future deaths, rather than protecting individuals and institutions from censure. It would also help inquiries become more effective and less protracted, benefiting the bereaved and survivors, and thus fulfilling the UK’s obligations under Articles 2 and 3 ECHR.

The Report also noted that notwithstanding the removal of means testing for exceptional case funding in inquests, there remains an inequality of arms in terms of access to legal advice and representation between the public bodies and officials appearing before an inquest or inquiry and the bereaved families. The Report urges the Government to take steps to ensure that families receive proportionate legal representation at inquests and inquiries whenever the state has its own representation.

The full report is available here.

Infected Blood Inquiry Report

On 20 May 2024, the Infected Blood Inquiry published its report, which is available here.

The report found that around 3,000 people had died after receiving contaminated blood from the health service and that doctors, bodies (including the NHS), and governments had repeatedly failed victims.

The report sets out a “catalogue of failures” which amounted to a “calamity”. It noted that the scandal was “not an accident” and that there had been a lack of openness, inquiry, accountability, and elements of “downright deception”. The Chair concluded that "[t]he infections happened because those in authority – doctors, the blood services and successive governments - did not put patient safety first.".

By Harriet Wakeman