Connah v Plymouth Hospitals NHS Trust & Ors

An order under section 13 of the Coroners Act 1988 may be made only where the statutory conditions are satisfied. The court must be satisfied that a coroner has refused or neglected to hold an inquest which ought to be held, or that an existing inquest should be reopened in the interests of justice. The circumstances in which an inquest ought to be held are confined to those identified by sections 8, 14 and 15. A coroner cannot acquire jurisdiction through an undertaking, instructions from another coroner, or agreement with a claimant. A decision not to report under section 15 may be reviewed only on conventional public-law grounds, including irrationality in the recognised sense.

The claimant applied, with the Attorney General’s fiat, under section 13 of the Coroners Act 1988 for an inquest into the death of his wife in 1998. He alleged that medical treatment had been wrongly administered and that medical records had been falsified. Four defendants were named, including the responsible NHS trust and coroners in Greater Manchester, Plymouth and Cornwall.

The claimant also challenged the Cornwall coroner’s decision not to report the matter to the Secretary of State under section 15. The central issues were whether any defendant had jurisdiction or a duty to hold or initiate an inquest, and whether the Cornwall coroner’s decision was irrational.

1. The application under section 13 of the Coroners Act 1988 was dismissed. The NHS trust was not a coroner and could not be subject to an order to hold an inquest. The court could grant relief only if a coroner was refusing or neglecting to hold an inquest which ought to be held, or if an existing inquest required reconsideration under section 13(1)(b).
2. The statutory scheme confined the relevant circumstances to sections 8, 14 and 15. The Greater Manchester coroner had never had jurisdiction under section 8, had not been requested to assume jurisdiction under section 14, and had received no direction under section 15. Any alleged undertaking or instruction could not create jurisdiction. The Plymouth coroner was in the same position.
3. The Cornwall coroner could have reported to the Secretary of State under section 15 because the death occurred in her district and the body had been destroyed by cremation. However, the evidence supported her conclusion that the death was neither unnatural nor of unknown cause.
4. It was open to the court to treat the proceedings as an application for judicial review of the decision not to report under section 15. Applying the conventional public-law standard identified in Terry v East Sussex Coroner [2002] QB 312, 319E–F, there was no irrationality. The application was therefore dismissed.

The judgment records earlier procedural proceedings in the related negligence action, including a Court of Appeal decision reported as [2006] EWCA Civ 1616. The present proceedings were determined at first instance in the Administrative Court.