Court guidance provided on Pre-Inquest Review Hearings

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Case facts
In Ernest Andrew Brown v HM Coroner for Norfolk & Chief Constable of Norfolk (interested party) [1] the claimant, Ernest Brown made an application to the High Court for an order that the inquest verdict on the death of his step-daughter, Joanne Foreman, be quashed and that a fresh coroner’s investigation should be held.

In his application the claimant set out various reasons why he believed that the original inquest process had not been fairly, honestly or, properly conducted. He claimed that the original police investigation which took place into the circumstances of the death was inadequate and, in consequence, the evidence presented to the Coroner at the inquest was incomplete and inaccurate. The inquest was conducted upon the general mistaken assumption that, the deceased had self-injected insulin which may have been the cause of her death. But, neither the police nor the Coroner’s officer drew the Coroner’s attention to the findings of the paramedic team which included an entirely normal blood glucose analysis made at the scene. This fact meant that insulin would have played no significant role in deceased’s death. The claimant was also highly critical of the over-familiarity with and a conversation between the Coroner and the investigating police authority.
The High Court granted the application to quash the original inquest verdict and ordered a fresh investigation.

The Court provided clear guidance on good practice and a Coroner’s expected conduct during the Inquest process:

  • where held, a PIRH is an important stage of the inquest process
  • the Coroner should ensure that all interested persons, including bereaved families, have sufficient notice of the matters to be discussed.
  • Coroners should provide in advance a written agenda tailored to the individual case and, if appropriate, express provisional views to encourage or promote responses
    the agenda in the more complex or difficult cases, should include:

    • a list of interested persons
    • a proposed list of witnesses (identifying who might be called and whose statements might be read out)
    • the issues to be considered at the Inquest
    • the scope of the evidence
    • a statement as to whether a jury would be required
    • a statement as to whether Article 2 of the European
    • Convention on Human Rights is engaged
    • issues of disclosure
    • the date of the final hearing
    • any other relevant matters.
  • in a complex investigation, interested persons should be invited to respond in writing to the Coroner’s agenda in advance of any PIRH
  • the Coroner should ensure interested persons have sufficient disclosure of relevant statements and documents before the hearing so as to be able to address the agenda on an informed basis
  • Coroners should avoid giving the impression at a PIRH that the findings and conclusions of the Inquest are in any way predetermined, even when the evidence points substantially in one direction
  • Coroners should take care in their dealings with interested persons not to give the impression of bias or favouritism
  • Coroners’ communications, whether oral or written, should be made in such a way that they do not engender concern
  • a Coroner should be careful in correspondence with an interested person (such as the police) not to appear to be too familiar with or close to the correspondent
  • Coroners should only write letters and emails in the course of their work which would stand the test of looking fair and unbiased if read out as part of litigation proceedings in Court.

The guidance provided by the High Court in this case makes for essential reading for any legal representative or interested parties, who may be involved in the inquest process.

If the recommended guidelines are followed it will avoid or at least reduce the risk of complaints which are directed at Coroners in the future. If the guidelines are complied with, interested parties are more likely to accept that there has been a fair and just inquest process, and any verdict arrived at has only been reached after a proper, full and careful analysis of all the available evidence.

[1] (2014) EWHC 187 (Admin)