Mullholland v HM Coroner for St Pancras

An application for a fresh inquest under Coroners Act 1988, section 13, requires the court to assess whether another inquest is necessary or desirable in the interests of justice. The likelihood of a different verdict is highly important and may be decisive. An inquest is a fact-finding inquiry into the limited statutory questions. It is not an investigation into civil or criminal liability. Procedural decisions, including the admission of statements and refusal of an adjournment, are lawful where the coroner has acted fairly, considered the relevant evidence and maintained proper focus on the inquest’s legitimate purpose. Fresh medical evidence will not justify another inquest where it rests on unrealistic assumptions, does not disclose a realistic prospect of a different verdict, or cannot establish a gross failure and a clear causal connection with the death.

The claimant sought judicial review of an inquest into the death of John Bunker, whose jury returned a verdict of accidental death. She also applied under section 13 of the Coroners Act 1988 for a fresh inquest. The challenges concerned the reading of witness statements under rule 37 of the Coroners Rules 1984, restrictions on cross-examination, an alleged unexplained delay before hospital treatment, and refusal to adjourn the inquest. Further medical reports suggested that earlier or more active treatment might have created a chance of survival. The central questions were whether the inquest was procedurally defective and whether the fresh evidence made another inquest necessary or desirable in the interests of justice.

1. Judicial review dismissed. The Deputy Coroner acted lawfully in admitting statements under rule 37(1). The evidence was relevant, unlikely to be disputed, and no timely objection had been made. The witnesses’ unavailability supplied an additional basis on which rule 37(2) might have been used.
2. The restriction on cross-examination by reference to Metropolitan Police Special Notice 37/97 was proper. Questions about what the officers did, whether they knew of the notice, and what it advised were permitted. Further questioning would have been irrelevant and liable to distract the jury.
3. The alleged time gap was not established. When the 999 call, ambulance record, police evidence and hospital records were considered together, the relevant witnesses had adequately addressed the period between the police station and hospital.
4. The refusal to adjourn was lawful. The proposed expert had not been identified and no indication had been given of the evidence he would provide. Starting the inquest again a year later was not shown to serve the interests of justice, particularly given the likely unavailability of a material witness.
5. Section 13 requires consideration of whether a fresh inquest would realistically produce a different verdict. The reports of Mr Gavalas and Mr Watkins assumed facts which were not established, including an immediate hospital admission and a fuller history of loss of consciousness. They did not demonstrate a gross failure in the system or a clear and direct causal connection between any failure and the death. Any complaint about hospital treatment was more appropriately pursued in civil proceedings.
6. The application for relief under section 13 was therefore dismissed. The coroner was awarded the costs of the earlier abortive hearing and this hearing. No order was made for the Metropolitan Police Commissioner’s costs, subject to detailed assessment of the publicly funded claimant’s liability.

The judgment itself does not state any earlier appellate decision in this litigation. It records that judicial review proceedings were commenced on 21 February 2002 and that the section 13 application was later joined for hearing.