Sreedharan, R (on the application of) v HM Coroner for the County of Greater Manchester (Manchester City District)

A coroner conducting an Article 2 inquest must investigate fully, fairly and fearlessly, but retains discretion to set the bounds of the inquiry. The scope is not confined to the immediate events of death where wider evidence is relevant to causation, responsibility, credibility or the circumstances in which the deceased died. A court will not interfere on a renewed permission application unless there is an arguable basis for concluding that the coroner acted unlawfully or unreasonably. Evidence concerning a practitioner’s prescribing history, knowledge, credibility and related investigations may fall within the legitimate scope of such an inquest, provided the inquiry remains fair and balanced.

Dr Sreedharan sought permission to apply for judicial review of a jury’s verdict of unlawful killing at the inquest into David Donohue’s death. The verdict followed a 35-day Article 2 inquest concerning death from chlormethiazole and alcohol toxicity after the claimant prescribed Heminevrin to the deceased.

The claimant argued that the coroner had unlawfully widened the inquest into an inquiry into his conduct, contrary to the Coroners Act 1988 and the Coroners Rules 1984. The central issue was whether the evidence about his prescribing history, medical practice, record keeping, credibility and related investigations was arguably outside the legitimate scope of the inquiry.

1. Renewed permission refused. The claimant had no arguable case that the coroner’s conduct, or the jury’s verdict, could successfully be impugned at a substantive hearing.
2. An Article 2 inquest, applying the approach in R (Middleton) v West Somerset Coroner [2004] AC 182, required a thorough inquiry into the death and its circumstances. The meaning of “how” included the means and circumstances in which the deceased came by his death. That made the prescription of Heminevrin, the claimant’s knowledge, the history of prescribing and the deceased’s relevant medical history central matters for the jury.
3. The coroner had a discretion to determine the scope and conduct of the inquiry. The requirement that the investigation be full, fair and fearless did not remove that discretion. The court applied the principles stated in R v HM Coroner for North Humberside, ex parte Jamieson [1995] QB 1 and in R v Coroner for Lincolnshire, ex parte Hay (19 February 1999, CO/2155/97 & CO/2210/98).
4. The evidence about the claimant’s previous prescriptions, Patient X, other drugs, credibility, the GMC and PCT investigations, and the conduct of the ambulance service and police was not arguably irrelevant or outside the coroner’s discretion. The inquiry was full, balanced and thorough. The claimant had not sought rulings at the inquest on the matters now challenged.
5. The coroner’s directions were prepared with counsel’s involvement and were not arguably unreasonable or unfair. The possible intervening fault of others and the prominence given to that issue were matters of judgment, and no Wednesbury error was arguable.

The judgment concerns a renewed application for permission to apply for judicial review. Permission had previously been refused on the papers by Sharp J. The Divisional Court refused the renewed application.