Lawrance, R (on the application of) v HM Coroner for West Somerset

A coroner’s decision under section 15 of the Coroners Act 1988 not to refer a death to the Secretary of State may be challenged only on ordinary public-law grounds of illegality or Wednesbury irrationality. The court must ask whether no reasonable coroner could have reached the decision. An inquest is confined to identifying the deceased and determining how, where and when the death occurred; it is not a means of investigating alleged medical negligence during the preceding years. Relevant alternative remedies and delay may also weigh against judicial review.

The claimant sought judicial review to compel the defendant coroner to initiate an inquest into her father’s death in 1999. The death had been certified as resulting from myocardial infarction and the body had been cremated before the coroner became involved. The claimant alleged that negligent medical treatment, rather than the certified cause, had caused the death. The coroner declined to refer the matter to the Secretary of State under section 15 of the Coroners Act 1988. The issues were whether that decision was unlawful and whether an inquest could address the claimant’s concerns.

1. The claim was refused. The coroner’s decision not to refer the matter to the Secretary of State was not unlawful.
2. Applying Canning v Her Majesty’s Coroner for the County of Northampton [2006] EWCA Civ 1225, the court held that the decision could be impugned only on grounds of illegality or Wednesbury irrationality. This required a conclusion that no reasonable coroner could have reached it.
3. The claimant had produced no independent evidence supporting the allegation of gross medical negligence causing death. The deceased’s age, the certified cause of death and the absence of such evidence meant that the coroner’s decision could not be characterised as irrational.
4. Even if an inquest were ordered, Rule 36 of the 1984 Coroners Rules confined its scope to identifying the deceased and determining how, where and when the deceased came by his death. It would not provide a general investigation into medical treatment during the preceding two years.
5. The court also noted the potential availability of other remedies, including an application under section 13 of the Coroners Act 1988, and the substantial delay in bringing judicial review proceedings. The application was refused and no order for costs was made.