Canning, R (on the application of) v Her Majesty's Coroner for the County of Northampton

For the purposes of Coroners Act 1988, a death from natural causes may be treated as unnatural where there is reasonable cause to suspect that medical neglect, lack of care or another culpable human failure contributed to it. The threshold is not met merely because an expert considers that an earlier medical assessment would have been prudent. A coroner’s decision whether to hold an inquest is reviewable on orthodox Wednesbury grounds. Article 2 does not independently require an inquest where there is no evidence of culpable failure going beyond simple negligence.

The claimant sought, under section 13(1) of the Coroners Act 1988, an order requiring the defendant coroner to hold an inquest into the death of his severely disabled fourteen-year-old son. The coroner had concluded that the death was from natural causes and that there was no evidence of culpable failing. Medical evidence suggested that the child had developed a fatal volvulus before his death, but did not explain how an examination on the previous evening would have led to recognition of the need for urgent surgery. The issues were whether the coroner had reasonable cause to suspect an unnatural death under section 8(1)(a), and whether Article 2 required a separate investigation.

1. Application dismissed. The coroner’s decision was lawful and was not irrational on Wednesbury grounds.
2. Under section 8(1)(a) of the Coroners Act 1988, a natural death may be regarded as unnatural where there is reasonable cause to suspect that medical neglect, lack of care or other culpable human failure contributed to it. The guidance in R Touche v Inner London North Coroner [2001] 1 QB 383 required a reasonable suspicion of a gross failure to provide basic medical attention where the need was obvious.
3. The evidence did not establish a reasonable basis for such suspicion. The child’s symptoms were intermittent and difficult to interpret. The expert evidence did not show that an examination then would have disclosed the volvulus or led to timely surgery.
4. Article 2 did not provide an independent basis for relief. Following Goodson v Her Majesty’s Coroner for Bedfordshire and Luton and Luton and Dunstable Hospital NHS Trust [2004] EWHC Admin 2931, there was no sufficient evidence of culpable failure, or conduct going beyond simple negligence, to engage the procedural obligation relied upon.

This was a first-instance judicial review application in the Administrative Court. Permission to appeal was not granted by this court; the claimant remained entitled to seek permission from the Court of Appeal.