Sutovic, R (on the application of) v HM Coroner Northern District of Greater London

Under the Coroners Act 1988, an inquest ordinarily establishes who the deceased was and by what means, when and where death occurred. The ordinary meaning of how concerns the means of death, not the wider circumstances. Article 2 of the European Convention extends that duty only where it applies. A failure to announce the right to object to documentary evidence is a procedural irregularity, but relief depends on whether it affected the outcome. Under section 13, a fresh inquest may be ordered where new evidence may produce a different verdict or materially alter the recorded circumstances. A probability of a different verdict is unnecessary. Later evidence showing investigative shortcomings and possible violence justified a fresh inquest before a different coroner.

The claimant challenged an open verdict returned after the death of her son in Belgrade and the subsequent return of his body to North London. She sought judicial review for procedural irregularity and insufficiency of inquiry. She also applied, with the Attorney-General’s consent, under section 13 of the Coroners Act 1988 for the original inquisition to be quashed and another inquest ordered.

The central issues were whether the coroner’s failure to comply with the documentary-evidence procedure affected the original verdict, and whether new evidence concerning the foreign investigation, possible facial injuries and blood at the scene made another inquest necessary or desirable in the interests of justice.

The court dismissed the judicial review claim but allowed the application under section 13 and ordered a fresh inquest before a different coroner.

1. Scope of an inquest. An inquest is a fact-finding inquiry directed to identifying the deceased and establishing how, when and where the deceased came by death. Applying R v North Humberside and Scunthorpe Coroner, ex p Jamieson [1995] QB 1, how ordinarily means by what means the death occurred. It does not ordinarily require investigation of the wider circumstances. The Article 2 qualification identified in R(Middleton) v West Somerset Coroner [2004] 2 AC 182 did not apply to a death in Belgrade on the facts before the court.
2. Procedural irregularity. The coroner’s failure publicly to announce the claimant’s right to object to documentary evidence breached Rule 37(3) of the Coroners Rules 1984. The absence of witnesses at the resumed hearing did not establish that they were unable to give evidence within a reasonable period. Nevertheless, the error did not affect the outcome. In the light of two consistent autopsies and the evidence then available, the open verdict recording morphine poisoning was inevitable.
3. Section 13. The relevant considerations included the possibility, rather than probability, of a different verdict, shortcomings in the original inquest, and new evidence concerning matters not previously investigated. The possibility of a different verdict was important but not conclusive. A fresh inquest could be justified even where another verdict appeared unlikely.
4. Application. The later Serbian Ministry of Interior Affairs report exposed serious investigative deficiencies. Further expert evidence concerning possible violence and blood at the scene had not been available at the original inquest and had never been fully investigated. In an open-verdict case, a materially different account of the circumstances could itself justify a further inquest. The public interest therefore required a fresh inquest, leaving the new coroner to sift reliable evidence from material lacking a sound foundation.

First-instance proceedings. The judgment records that an open verdict was returned at the inquest on 27 September 2004. The High Court then determined the judicial review claim and the separate application under section 13 of the Coroners Act 1988.