Dowler, R (on the application of) v Coroner for North London

Under section 13 of the Coroners Act 1988, the High Court may quash an inquisition and order another inquest where procedural irregularity, insufficient inquiry, or new facts or evidence make that course necessary or desirable in the interests of justice.

A person whose conduct may be called into question must receive the procedural protections provided by the Coroners Rules, including notice and the opportunity to examine or call evidence. A new inquest may be directed before a different coroner even without proof of actual or apparent bias where the previous coroner’s serious adverse findings and procedural failures create embarrassment or a serious risk to the appearance of impartiality.

Dr Dowler, a general practitioner, applied under section 13 of the Coroners Act 1988, pursuant to an Attorney-General’s fiat, to quash the inquisition into Mr Suji’s death and obtain a fresh inquest before a different coroner.

The inquest concluded that the death had been contributed to by neglect, implicating Dr Dowler. She had not been notified of the inquest, called to give evidence, or represented at it. The coroner accepted that a new inquest should be held but opposed the appointment of a different coroner. The issues were whether the inquisition should be quashed and whether the fresh inquest should be conducted by another coroner.

1. Section 13 was satisfied on several grounds. The original inquiry was procedurally irregular and insufficient because Dr Dowler’s conduct was called into question without giving her the protections required by Rules 20 and 24 of the Coroners Rules.

2. Dr Dowler’s proposed evidence, consultation notes, and a new expert report constituted new facts or evidence relevant to the finding of neglect. The original conclusion had been reached without that evidence. It was therefore necessary and desirable in the interests of justice to quash the inquisition and hold another inquest.

3. The power under section 13(2) to order a fresh inquest before a different coroner is discretionary. Proof of actual or apparent bias is not an essential precondition. Embarrassment, an incorrect approach at the first inquest, or an inquiry in which evidence had not been fairly ventilated may justify appointing another coroner.

4. The coroner had made strong adverse findings without hearing Dr Dowler’s account or the relevant expert evidence. His procedural failures, the criticism made of his conduct, and the absence of an explanation created at least a possibility of bias and a serious risk to the appearance of impartiality. Dr Dowler’s position might also impair her ability to present her case confidently and effectively before the same coroner.

5. The inquisition was quashed and a new inquest ordered before a different coroner.

Not stated in the judgment.