Takoushis, R (on the application of) v HM Coroner for Inner North London

Section 8(3)(d) of the Coroner’s Act 1988 requires a jury where there is reason to suspect both that the circumstances of death may recur and that reasonable measures could and should be taken to prevent similar fatalities. Causation is unnecessary. The provision does not require the coroner to decide that the existing system is the best available. A system may be capable of improvement while remaining reasonable. Judicial review is confined to material misdirection or a decision no reasonable coroner could reach. An inquisitorial inquest does not generally give the deceased’s family a right to call its own expert, even where the hospital calls evidence about its procedures. The coroner retains a broad discretion over the evidence needed to conduct a fair and adequate inquiry.

The claimant sought judicial review of an inquest into the death of her husband, who had left a hospital accident and emergency department after being assessed as at high risk of self-harm and subsequently drowned. She challenged the coroner’s refusal to summon a jury under section 8(3)(d) of the Coroner’s Act 1988 and his refusal to adjourn the inquest so that she could call expert evidence about the hospital’s procedures.

The coroner considered that the hospital had a reasonable system, although it had not been properly implemented on the occasion in question. He held that the circumstances did not disclose a systemic failing and returned a verdict of suicide. The central issues were whether the statutory conditions for a jury were met and whether the inquiry was inadequate without the claimant’s expert evidence.

1. The claim was dismissed. The coroner’s refusal to summon a jury and refusal to permit additional expert evidence were lawful.
2. Section 8(3)(d) of the Coroner’s Act 1988 contains two conditions, derived from R v Her Majesty’s Coroner at Hammersmith, ex parte Peach [1980] QB 211: there must be a reasonable prospect of recurrence of the relevant circumstances, and reasonable measures must exist which could and should be taken to prevent similar fatalities. The circumstances need not have caused the death; it is sufficient that the death occurred in them.
3. The coroner’s conclusion that recurrence was not reasonably suspected was irrational on the evidence. The hospital’s own material stated that patients following attempted suicide absconded regularly. That error did not determine the claim, however, because the coroner was entitled to conclude that the hospital had a reasonable system and that the incident resulted from a specific failure to implement it.
4. The statutory test is whether the system could reasonably be changed and ought to be changed, not whether it is ideal or the best available. Later improvements do not by themselves establish that the earlier system was defective. The coroner had considered those improvements and was entitled to find that no systemic failing had been shown.
5. The inquest was inquisitorial. Although Article 2 of the Convention may require an independent investigation and appropriate family involvement, it does not give the family an automatic right to call an expert of its choice. The coroner had a broad discretion to determine what evidence would assist him. His decision was particularly justified because the proposed expert evidence concerned the general adequacy of a system, whereas the remaining issue was the particular failure to see the deceased within the required period.

Not stated in the judgment.