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

A coroner must conduct a full, fair and fearless investigation of all relevant circumstances of a death. Where a hospital system may have contributed to a death, the inquiry must examine both the design of that system and its operation. The coroner may not assume, without sufficient evidence, that a failure was solely operational rather than systemic.

Under section 8(3)(d) of the Coroners Act 1988, the question whether a jury is mandatory is assessed prospectively at the time of the inquest. A jury is not required if remedial measures mean that the relevant risk will not continue or recur, although the discretionary power remains. In an ordinary hospital-negligence case, Article 2 requires a practical and effective overall system for investigation and civil accountability, rather than the enhanced custody-death inquest procedure.

Mrs Takoushis sought judicial review of decisions made during the inquest into the death of her husband, who left a hospital accident and emergency department after being assessed as at high risk of self-harm and later died by suicide.

The coroner refused to summon a jury under section 8(3)(d) of the Coroners Act 1988 and refused an adjournment to permit the family to obtain expert evidence. He treated the delay before medical assessment as an operational failure, rather than a possible defect in the hospital system. Elias J dismissed the claim for judicial review: [2004] EWHC 2922 (Admin).

The appeal concerned whether the inquest had adequately investigated the hospital system, the prospective operation of section 8(3)(d), and whether Article 2 of the European Convention on Human Rights required an enhanced inquest procedure.

1. Appeal allowed. The court quashed the inquest verdict and ordered a new inquest. The coroner’s decisions before and at the conclusion of the inquest were flawed because they rested on an inadequately investigated distinction between a systemic and an operational failure.

2. A coroner’s duty is to investigate the relevant facts fully, fairly and fearlessly. Although an inquest cannot determine civil or criminal liability, that restriction does not justify a superficial inquiry. The principles in R v N Humberside Coroner ex p Jamieson [1995] QB 1 and R v Inner West London Coroner ex p Dallaglio [1994] 34 All ER 139 required investigation of both the hospital’s triage system and its operation on the day.

3. The evidence did not permit the coroner to conclude that the delay in medical assessment was merely an operational error. He had not investigated why the deceased was not seen within the target time, what safeguards applied when that time could not be met, or whether pressure on the department revealed a defect in the system. Those matters could have affected both the cause of the failure and the adequacy of future safeguards.

4. Section 8(3)(d) of the Coroners Act 1988 is directed to the future at the time of the inquest. A jury is mandatory only where the continuance or possible recurrence of the circumstances is prejudicial to public health or safety. Subsequent effective remedial steps may therefore remove that obligation. The coroner nevertheless retains the discretionary power in section 8(4).

5. The court further held, on a point not necessary to the disposal of the appeal, that ordinary alleged medical negligence in an NHS hospital does not attract the enhanced investigative requirements applicable to a death in custody. Article 2 requires a practical and effective system for investigating the facts and determining civil liability. In England, a full traditional inquest together with the available civil, criminal and disciplinary procedures could satisfy that requirement. The deceased had not been detained by the state.

6. The form of the new investigation, including whether to summon a jury or receive expert evidence, was left to the coroner. A person seeking expert evidence should identify the proposed expert and the substance of the anticipated evidence.

• Court of Appeal (Civil Division) — allowed the appeal, quashed the inquest verdict and ordered a new inquest: [2005] EWCA Civ 1440 .
• Administrative Court (High Court) — Elias J dismissed the application for judicial review of the coroner’s refusal to summon a jury and adjourn for expert evidence: [2004] EWHC 2922 (Admin) .