Howlett v HM Coroner for the County of Devon & Anor

Under section 13 of the Coroners Act, the High Court may order a fresh inquest where this is necessary or desirable in the interests of justice because of insufficiency of inquiry, new evidence, procedural irregularity or otherwise.

The court must consider the possibility, rather than merely the probability, of a different verdict; the shortcomings in the original inquest; the significance of new evidence; and the lapse of time. A fresh inquest may be ordered even where the original verdict is likely to remain unchanged. An open verdict should be used only where strictly necessary.

Rachel Whitear died in Devon in 2000. An inquest considered limited evidence, including a toxicology test showing a low morphine level, and returned an open verdict.

Following a later investigation, the claimant applied under section 13 of the Coroners Act, with the support of Rachel’s parents, for the original inquest to be quashed and a fresh inquest ordered. New toxicology and post-mortem evidence indicated opiate intoxication. The application also alleged insufficiency of inquiry and procedural irregularity in the handling of documentary evidence.

1. Appeal allowed. The original inquest was quashed and a fresh inquest was directed before a different coroner from another district in the same administrative area.
2. The relevant considerations under section 13 of the Coroners Act included the possibility of a different verdict, the number and seriousness of shortcomings in the original inquest, the need to investigate new evidence, and the lapse of time since the death. A fresh inquest could be justified even where the original verdict was highly likely to remain unchanged.
3. The original inquiry was insufficient. The initial toxicology test was a preliminary test adapted for blood, despite the manufacturer’s warning that a more specific method was required. Once the result did not support the assumed heroin-overdose explanation, further toxicology should have been obtained. The failure to order a post-mortem also prevented proper consideration of other possible causes of death.
4. The later expert evidence materially strengthened the case for a fresh inquest. It could support a conclusion that the cause of death was heroin or opiate intoxication. Evidence concerning possible third-party involvement also merited consideration, although it was not likely by itself to establish unlawful killing.
5. The handling of witness statements amounted to an irregularity under rule 37 of the Coroners Rules 1984. The interested parties could not exercise their right to object to documentary evidence on a reasonable and informed basis when statements were disclosed only as they were read.
6. The court declined to determine the separate Article 2 submission because its correctness was not self-evident and it had not been tested by adversarial argument. The costs applications were to be determined on written submissions after the coroner had been given an opportunity to respond.

An inquest held in Exmouth on 1 December 2000 returned an open verdict after the coroner was unable to establish the cause of death.

The High Court, exercising its jurisdiction under section 13 of the Coroners Act, allowed the application and directed a fresh inquest before a different coroner.