Bicknell v HM Coroner for Birmingham

For the purposes of deciding whether an inquest ought to be held, reasonable cause to suspect an unnatural death does not require proof of a direct or single causative link. A combination of circumstances may suffice, including an unexpected death from natural causes following possible culpable human failure. Where the statutory threshold is met but the body is unavailable, the coroner should report the facts to the Secretary of State under the Coroners Act 1988. The court declined to determine the separate investigative obligation under Article 2 of the ECHR.

Mrs Hazel Bicknell challenged the decision of the HM Coroner for Birmingham and Solihull not to hold an inquest into the death of her father, Leslie Vines, at a nursing home. The body had been cremated before the coroner was informed, so the ordinary duty under section 8 of the Coroners Act 1988 could not operate directly. The claim therefore concerned the coroner’s consideration of whether an inquest ought to be held and whether he should report the facts to the Secretary of State under section 15. The claimant also relied on Article 2 of the ECHR.

1. The claim succeeded. The coroner should report the facts to the Secretary of State under section 15 of the Coroners Act 1988. The question whether an inquest should ultimately be held was for the Secretary of State.

2. The court did not resolve whether the circumstances engaging section 15 are wider or narrower than those in section 8. The coroner had approached the matter by applying the section 8 threshold, and the challenge was determined on that basis.

3. The statutory test required reasonable cause to suspect an unnatural death. It did not require proof of a causative link between improper treatment and death. The possible excessive administration of haloperidol, the restrictive use of a bucket chair, possible delay or failure in antibiotic treatment, the family’s observations and wider concerns about the nursing home collectively satisfied that threshold.

4. The court applied the approach in R (Touche) v Inner London North Coroner, [2001] QB 1206; [2001] EWCA Civ 383. A death from natural causes may be unnatural where it is unexpected and would not have occurred but for culpable human failure. The possibility of a neglect verdict may independently support the conclusion that an inquest ought to be held. Naturalness should not be assessed solely by searching for one dominant cause; a combination of circumstances may be relevant.

5. The court declined to decide the Article 2 issue. It expressed reluctance to determine the adequacy of the State’s investigative compliance without the Secretary of State as a party, referring to R (Middleton) v West Somerset Coroner, [2004] 2 AC 182; [2004] UKHL 10.

6. The passage of time and evidential difficulties did not alter the court’s conclusion. Those matters might be relevant to the Secretary of State’s later decision. The coroner indicated that he would make the required report.

Permission to apply for judicial review was granted by Burton J on 20 July 2006. The judgment was a first-instance decision of the Administrative Court; no lower court decision was under appeal.