Canning v HM Coroner for the County of Northampton

A coroner must hold an inquest where there is reasonable cause to suspect an unnatural death under section 8(1) of the Coroner’s Act 1988. The threshold is low and does not require a prima facie case. A natural death may be treated as unnatural where it would not have occurred but for culpable human failure. A refusal to hold an inquest is reviewable only for illegality or irrationality. Evidence that a patient was unsettled, together with an expert view that medical assessment would have been prudent, does not by itself establish reasonable cause to suspect culpability. The appeal was dismissed because the evidence did not make the coroner’s conclusion irrational.

Francis Canning, a severely disabled child, died from a volvulus of the small bowel. His father applied under section 13(1) of the Coroner’s Act 1988 for an order requiring the Northamptonshire coroner to hold an inquest, arguing that the death might have resulted from culpable failure to obtain medical assessment during the preceding night.

The coroner refused, concluding that Francis had died from natural causes and that there was no culpable failing. The Divisional Court dismissed the application, holding that the refusal was not irrational or otherwise unlawful. The central issue on appeal was whether the original and further medical evidence gave reasonable cause to suspect an unnatural death and rendered the coroner’s decision unlawful.

The appeal was dismissed unanimously. Carnwath LJ gave the judgment, with Keene LJ and Ward LJ agreeing.

1. The duty under section 8(1) of the Coroner’s Act 1988 required an inquest where there was reasonable cause to suspect an unnatural death. The accepted formulation from R (Touche) v Inner London North Coroner treated a wholly unsuspected natural death as unnatural where it would not have occurred but for culpable human failure. The threshold was low and did not require a prima facie case, as explained in Hussein v Choung Fook Kam. A refusal to hold an inquest could be challenged only on Wednesbury grounds, namely irrationality or illegality, with support from Touche and Terry v East Sussex Coroner.
2. The Article 2 argument was not independently determined. The claimant had accepted that it would be difficult to establish an Article 2 case without succeeding under domestic law. The court noted that R (Takoushis) v HM Coroner for Inner North London and Guys and St Thomas’ Hospital NHS Trust and the Commissioner of the Metropolitan Police had approved the relevant Strasbourg principles and held that the statutory system complied with Article 2.
3. The court considered the further evidence from Professor Milla because the coroner had a continuing duty. Even assuming that evidence could be considered, it did not show that anyone had been culpable or provide reasonable cause to suspect culpability. At its highest, it suggested that medical assessment would have been prudent, while recognising the difficulty of interpreting Francis’s symptoms and the possibility of constipation as an alternative explanation.
4. Evidence of inconsistencies or possible further investigations did not make the coroner’s conclusion irrational. The coroner was entitled to conclude that the statutory threshold was not met and that further inquiry would achieve nothing. The formal order was: appeal dismissed.

• Court of Appeal (Civil Division): The appeal from the Divisional Court was dismissed unanimously. The court’s judgment is reported at [2006] EWCA Civ 1225.
• Queen’s Bench Division, Divisional Court: Laws LJ, with Ouseley J agreeing, dismissed the application for an order requiring the coroner to hold an inquest, finding no irrational or otherwise unlawful decision.