Medihani, R (on the application of) v Coroner for Inner South District of Greater London

A coroner’s power to resume an adjourned inquest after criminal proceedings is highly discretionary, but the statutory threshold remains whether there is sufficient cause. A decision refusing resumption is unlawful if the coroner materially misdirects herself or gives unreasonable weight to factors relevant to an arguable breach of the State’s Article 2 operational duty.

Where an inquest is the primary Article 2 investigation, the statutory question how the deceased came by death may extend to the circumstances and contributing factors. An arguable operational breach arises where the authorities knew or ought to have known of a real and immediate risk to an identified person’s life and failed to take measures within their powers which, judged reasonably, might have avoided that risk. A separate investigation that does not examine those issues may not satisfy the investigative obligation.

Arsema Dawitt, aged 15, was murdered by Thomas Nugesse after a period of threatening and controlling behaviour. Her mother had reported concerns to the police, and the Independent Police Complaints Commission later investigated aspects of police conduct.

The coroner had opened and adjourned an inquest pending criminal proceedings. After the criminal court found Nugesse had deliberately and unlawfully killed Arsema, the coroner decided not to resume the inquest. She considered that the available information did not show an arguable real and immediate risk to life or a failure by the police to take measures capable of avoiding it.

The claimant sought judicial review, arguing that the decision was unreasonable and that the criminal proceedings and IPCC investigation had not discharged the State’s Article 2 investigative obligation. The central issues were whether there was sufficient cause to resume the inquest and whether the coroner’s decision was lawful.

1. Decision quashed and inquest ordered. The coroner’s refusal to resume the inquest was unlawful. The inquest was to be held before a different coroner.
2. Under section 16(3) of the Coroners Act 1988, resumption after criminal proceedings requires only sufficient cause. The power is highly discretionary and is not confined by any requirement for exceptional circumstances. The approach in R (Dallaglio) v Inner West London Coroner [1994] All ER 139 was applied.
3. Where the procedural obligation under Article 2 requires an independent investigation and the inquest is the primary investigation, the statutory how question is read as extending to the means and circumstances of death. This includes contributing and underlying factors. The criminal proceedings, which focused on fitness to plead and the killing, had not explored the wider circumstances, and the IPCC investigation had not considered whether there was a real and immediate risk to life or whether reasonable preventive measures were available.
4. The court preferred Lord Bingham’s approach in Van Colle v Chief Constable of the Hertfordshire Police [2009] 1 AC 225: authorities may be treated as knowing what reasonable further enquiries would have revealed. On the information reported to police, there was at least an arguable real and immediate risk. The threat to kill, earlier violence, the age disparity, and Nugesse’s apparent jealousy and infatuation required proper weight. The coroner was wrong to treat the telephone form of the threat, Arsema’s denial, her wish that Nugesse be warned, and the delay in reporting as materially negating the risk.
5. The police could have contacted Nugesse, assessed the risk, considered arrest and bail conditions, and warned Arsema and her family about safety precautions. Those measures might reasonably have avoided or mitigated the risk. The coroner’s reasons were therefore unreasonable individually and cumulatively. The coroner’s counsel had acted neutrally and helpfully, so there was no order as to costs.

First-instance judicial review in the Administrative Court. The judgment records that permission was initially refused on paper by Mitting J but was later granted after an oral hearing before Ouseley J. The coroner’s decision was quashed and the matter directed to a new inquest.