In Ernest Andrew Brown (Claimant) v HM Coroner for Norfolk (Defendant)& Chief Constable of Norfolk (Interested Party) [2014] EWHC 187 (admin),
the High Court (Pitchford LJ and HHJ Thornton QC (Chief Coroner for England and
Wales) gave guidance to Coroners on the handling of pre-inquest review hearings
(“PIRs”), writes Rachel Galloway of Kings Healthcare Team.
The Claimant (the stepfather of the deceased) made an application
under s 13(1)(b) of the Coroners Act 1988 (as amended) for an order that an
inquest into the death of Joanne Foreman be quashed and a fresh investigation
be held.
It was common ground that the police investigation into the
circumstances of Ms Foreman’s death was inadequate. At inquest, the coroner was unable to find
the cause of death and recorded a narrative verdict accordingly. The PIR proceeded upon the assumption that although the precise cause of death could not be ascertained, the
self-ingestion of insulin and alcohol may well have been the cause (a view put
forward by an expert). After the full
inquest had concluded it became apparent that this assumption was
incorrect. The Paramedic team who
attended upon the deceased had taken a blood glucose analysis and the reading
was found to be entirely normal. This
reading had not been brought to the expert’s attention and expert evidence was
subsequently obtained which concluded that insulin had played no significant
role on the deceased’s death.
It was held that as a result of the blood sugar finding by the
paramedics not being available to the Coroner, the medical side of the
investigation into the death of Joanne had set off on the wrong track and never
got back on track. The absence of the
finding was so significant that it was desirable and in the interests of
justice that a fresh investigation and inquest be held.
However, HHJ Thornton QC went on to give some wider guidance to
Coroners on the handling of PIRs. He
endeavoured to identify “potential pitfalls” which could be avoided by good
practice.
He noted that the status of the PIR is now enshrined in Rule 6 of
the Coroners (Inquest) Rules 2013 (which came into force from the 25th
July 2013 for investigations started before and since). Rule 6 permits the Coroner to hold a PIR ‘at
any time during the course of an investigation and before an inquest’. Rule 26 of the 2013 Rules requires a coroner
to make and keep a recording of a PIR hearing.
In the present case, large parts of the recording was not available due
to apparent equipment failure. HHJ
Thornton QC stated at paragraph 38 of the Judgment (in respect of Rule 26):
“This requirement means
that a coroner conducting such a hearing should take reasonable steps to ensure
that the recording equipment is working well and that those who speak in court
do so in such a way that the recording can be transcribed with accuracy and in
full. An incomplete transcript is not
helpful. It may open the door (as in
this case) to allegations of tampering and deliberate and fraudulent removal of
key questions and answers”.
Further, HHJ Thornton QC made the following points:
(1)
In each case the Coroner should
ensure that all interested persons (particularly bereaved families) have
sufficient notice of the matters to be discussed at the PIR (where held);
(2) Coroners should provide a
written agenda in advance and, if appropriate, express provisional views so
that agreement or opposition can be expressed;
(3)
The agenda should include:
(a) A list of interested persons;
(b) A proposed list of witnesses identifying those who may be called and
those whose statements may be read;
(c)
The issues to be considered at
the inquest;
(d) The scope of the evidence;
(e) Whether a jury will be required;
(f)
Whether Article 2 is engaged;
(g) Any issues of disclosure;
(h) The date of the final hearing;
(i) Any other relevant matters.
(4)
In a complex or difficult
investigation, Interested Persons should be invited to respond to the Coroner’s
agenda in advance of the PIR hearing in writing, stating what they agree with
and what they do not agree with;
(5)
The Coroner should ensure that
Interested Persons (particularly those unrepresented) have sufficient
disclosure of the relevant statements and documents before the PIR hearing so
as to be able to address the agenda on an informed basis (in the present case,
HHJ Thornton QC was concerned that the Claimant may not have had access to the
Post Mortem Report or the Toxicology Reports prior to the PIR hearing);
(6)
Coroners should avoid giving
the impression at a PIR hearing (and in any documentation supplied before it) that the findings and conclusions of the inquest are in any way pre-determined,
even when the evidence points substantially in one direction. It may be necessary to explain in clear
language to unrepresented families that there is a difference between seeking
to identify the key issues and coming to a final conclusions;
(7)
Coroners should at all times
take care in their dealings with interested parties not to give the impression
of bias or favouritism. It appears that
the Claimant and his wife had overheard the Coroner and Police discussing the
deceased prior to the commencement of the PIR hearing. The Claimant asserted that he had overheard
the Detective Chief Inspector referring to the deceased as aggressive, suicidal
and drunk and describing the Claimant as difficult. HHJ Thornton QC stated that Coroners may need
to communicate with police officers investigating on their behalf, but their
communications, whether oral or written, should be made in such a way that they
will not engender concern to others that their interests are being treated as
secondary;
(8)
Coroners should be careful in
correspondence with an Interested Person, such as the police, not to appear too
familiar or too close to the correspondent and not encourage the same from the
correspondent, even though the Coroner may know the correspondent well during the
course of coroner work. He goes on: “Even the use of first names may not look
good to an outsider, particularly to somebody of the older generation”;
(9)
Coroners should only write
letters (and emails) in the course of their work which will stand the test of
looking fair and unbiased if and when read out in court in litigation.
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