Canning v Northhampton County Coroner

For an inquest to be mandatory under section 8(1) of the Coroner's Act 1988, there must be reasonable cause to suspect that the death was violent or unnatural. Possible culpable human failure may be relevant, but not every death in a care home, including the death of a disabled child, automatically requires an inquest. Systemic failures in institutional care may also be relevant to Article 2 of the Human Rights Convention. Permission to appeal was granted because there was some prospect of success, although the death might ultimately be found natural. The application concerning further expert evidence was adjourned, subject to disclosure of the expert's instructions.

Francis Canning, a severely disabled 14-year-old child, died after developing a volvulus causing infarction of the small bowel. His father asked the Northamptonshire coroner to hold an inquest. She declined, concluding that there was no evidence of culpable failure and that the death was natural.

The Divisional Court dismissed the appeal, holding that the coroner had not reached an unreasonable decision in the Wednesbury sense. The claimant sought permission to appeal and permission to rely on new evidence, including expert evidence concerning whether earlier medical assessment might have saved Francis’s life. The Court of Appeal considered whether there was a sufficient prospect of success on the issues of an unnatural death, possible systemic failures and Article 2 obligations.

1. Permission and new evidence. The Court of Appeal granted permission to appeal because there was at least some prospect that the appeal would succeed. The application to rely on Dr Milla’s further evidence was adjourned for consideration by the full court. The proposed evidence of Deborah Coles was not admitted at that stage. The instructions given to Dr Milla were ordered to be disclosed to the coroner and the court, and the coroner could file responsive evidence within 28 days.
2. Statutory threshold. Section 8(1) of the Coroner's Act 1988 requires an inquest where there is reasonable cause to suspect that the deceased died a violent or unnatural death. Possible culpable human failure may bear on whether a death is unnatural. The court did not finally determine whether the evidence satisfied that threshold.
3. Human-rights issue. Possible systemic failures in residential care, including staff training in recognising medical problems in severely disabled children, might raise an issue under Article 2 of the Human Rights Convention. The court noted that the argument had some support from R (Takoushis) v HM Coroner for Inner North London, but did not finally decide the issue.
4. Scope of the inquiry. Not every death in a care home, even the death of a disabled child, necessarily requires an inquest. It remained possible that the full court would conclude that this was a natural rather than an unnatural death.

• Court of Appeal (Civil Division): permission to appeal granted from the Divisional Court’s decision of 23 November 2005; the application to rely on further evidence was adjourned.
• Queen’s Bench Division, Divisional Court: appeal against the coroner’s refusal to hold an inquest dismissed on the basis that the coroner’s decision was not unreasonable in the Wednesbury sense.