Jones v HM Coroner for the Southern District of Greater London & Anor

Section 13 of the Coroners Act 1988 permits a further inquest where insufficiency of inquiry or new evidence makes it necessary or desirable in the interests of justice. The relevant question is whether there is a possibility of a different conclusion, not whether a different conclusion is probable.

An inquest into how a deceased came by his death is not necessarily confined to the immediate medical cause or final link in causation. The coroner must conduct a full, fair and fearless investigation of relevant facts, deciding how far down the causal chain inquiry should extend. Where further evidence could explain an otherwise unexplained death and may support a different verdict, a further inquest may be ordered. Wider public-health concerns may also make a further inquest necessary.

The claimant, the mother of a young man who died from fentanyl toxicity, applied under section 13 of the Coroners Act 1988, with the Attorney-General’s authority, to quash the inquisition and obtain a further inquest before a different coroner.

The original inquest established fentanyl toxicity and pneumonia as the causes of death and returned an open conclusion. It did not investigate how the deceased came to have exceptionally high fentanyl concentrations, the prescribing and repeat prescribing of fentanyl, or the possible contribution of prescribing and healthcare-system failures.

The issues were whether there had been an insufficiency of inquiry, whether new evidence created a possibility of a different conclusion, and whether wider public-health concerns supported a further inquest.

1. Application granted. The inquisition was quashed and a further inquest was ordered. The scope of the further inquest was for the presiding coroner to determine, although it appeared that it should be held with a jury.
2. Section 13(1)(b) of the Coroners Act 1988 is expressed in broad terms. The central considerations include the possibility, rather than probability, of a different verdict, shortcomings in the original inquest, and new evidence raising matters that were not investigated: R (on the application of Sutovic) v HM Coroner for Northern District of Greater London [2006] EWHC 1095 (Admin).
3. The statutory requirement to investigate how the deceased came by his death ordinarily means investigating by what means, under section 11(5)(b)(ii) of the 1988 Act and rule 36(1)(b) of the Coroners Rules 1984. It does not necessarily stop at the immediate cause of death. The coroner must determine where the causal chain becomes too remote, subject to the duty to conduct a full, fair and fearless investigation: R v HM Coroner for North Humberside and Scunthorpe, ex parte Jamieson [1995] QB 1; R v HM Coroner for Inner West London, ex parte Dallaglio [1995] 4 All ER 139.
4. The original inquest identified the exceptionally high fentanyl concentration but did not investigate how it arose. A proper inquiry would have considered whether the prescribed quantity could be fatal in particular circumstances, whether post-mortem concentrations reliably reflected concentrations at death, and how the successive prescriptions came to be issued. That inquiry required toxicological evidence. There was a possibility of an accidental-death conclusion at a further inquest.
5. The evidence of numerous unintended fentanyl-overdose deaths and concerns about prescribing practices established a wider public interest in a full and public inquiry. The fact that other investigations had addressed related issues privately did not remove the need for a further inquest.