D, R (on the application of) v Inner South London Assistant Deputy Coroner

An inquest need not provide every factual question proposed by a family, provided the verdict and questions enable the jury to express conclusions on how, when and where the deceased came by their death, understood as the means and circumstances of death. The coroner has a broad discretion as to how those conclusions should be elicited. The court should not interfere unless strong grounds are shown, applying at least a Wednesbury-type standard. Additional questions may properly be refused where they risk determining civil or criminal liability, producing contradictory findings, or undermining the coherence of the verdict.

The claimant challenged the Assistant Deputy Coroner’s refusal to put additional narrative-verdict questions to the jury at the inquest into the death of her son, who had been shot by police officers. The proposed questions concerned additional causal factors, the gravity of police failings and explanatory comments. The claimant relied on the procedural obligation under Article 2 of the Convention and section 11(5)(b)(ii) of the Coroners Act 1988. The central issue was whether the existing verdicts and questions sufficiently enabled the jury to determine by what means and in what circumstances the deceased came by his death.

1. Application refused. The existing lawful-killing or open verdicts, together with the agreed questionnaire, enabled the jury to ascertain by what means and in what circumstances the deceased came by his death, satisfying section 11(5)(b)(ii) of the Coroners Act 1988 and Rule 36(1)(b) of the Coroners Rules 1984.
2. The court followed the approach in R (Middleton) v West Somerset Coroner [2004] 2 AC 182. The coroner has a discretion to decide how best, in the particular case, to elicit the jury’s conclusions on the central issues. The court should not disturb that choice unless strong grounds are shown. The proposed additional questions were not required by Article 2.
3. Bubbins v United Kingdom [2005] ECHR 159 and McCann v United Kingdom [1995] 21 EHRR 97 demonstrated that Article 2 could be satisfied without the detailed questions sought in this case. The present questionnaire sought substantially more information than the inquests considered in those cases.
4. The proposed questions also created a substantial risk of infringing Rules 36(2) and 42 of the Coroners Rules 1984 by inviting opinions beyond the jury’s proper function or findings appearing to determine civil or criminal liability. They also risked contradictory or conflicting findings by requiring the jury to revisit conclusions already reached.
5. The observations in Hurst v London Northern District Coroner [2007] 2 AC 189 concerned a different issue and affirmed rather than undermined the approach in Middleton. The remainder of the judicial review claim was adjourned generally, with the usual detailed assessment of the claimant’s publicly funded costs.