Lepage, R (on the application of) v HM Assistant Deputy Coroner for Inner South London & Ors

In an Article 2 inquest, a coroner must investigate the central issues directly causative of the death, but need not investigate every possible or peripheral issue. The coroner has a broad discretion to determine the scope of the inquiry, the evidence to call and the matters to leave to the jury. That discretion must be exercised reasonably and fairly, applying Wednesbury principles. A possible but improbable cause of death need not be left to the jury. Judicial review will not interfere unless strong grounds are shown. The desirability of calling additional evidence as a matter of practical justice does not create a legal duty to do so.

The claimant sought judicial review of decisions made at an inquest into the death of an 18-year-old woman from acute cocaine toxicity after her arrest and detention at a police station. The coroner declined to call an additional forensic pathologist, declined to call further evidence about police training, and did not leave questions concerning restraint, strip-searching, training and medical advice to the jury.

The claimant argued that an Article 2 inquest required investigation of all possible causes of death and all possible systemic failings. The central issues were whether the coroner had acted unlawfully in limiting the inquiry and whether the disputed matters had to be left to the jury.

1. The application was dismissed. The coroner’s decisions were lawful and the inquest constituted an effective Article 2 investigation.
2. A coroner has a broad discretion to determine the scope of an inquest and to decide which witnesses and evidence are expedient. The discretion extends to expert witnesses. It must be exercised reasonably and fairly and will not be disturbed unless the decision was not properly open to the coroner on Wednesbury principles. The relevant statutory power was Coroners Act 1988, section 11(2).
3. The requirement to investigate fully, fairly and fearlessly does not require an unlimited inquiry. Under Article 2, the coroner must focus on matters directly causative of death and on issues which are, or appear arguably to be, central. The inquiry may extend wider than strictly required for the verdict, but the extent of that wider inquiry is principally for the coroner.
4. Following R (Lewis) v Mid and North Shropshire Coroner, a coroner has a power, but no duty, to leave to the jury circumstances which are possible but not probable causes of death. The absence of a Rule 43 report does not convert that power into a duty.
5. The medical evidence was effectively unanimous that cocaine toxicity caused the death and that restraint, search and force had not contributed to it. The proposed additional expert evidence was speculative, added nothing material and did not raise a sufficiently supported alternative causative issue. The coroner therefore acted lawfully in refusing to call it.
6. The evidence concerning police training, restraint, search and the advice given by the police doctor did not disclose a substantive issue requiring determination by the jury. The matters were investigated sufficiently, and there was no evidential basis for leaving them as possible causes or failings.
7. The court observed that calling the additional expert might have been preferable as a matter of practical justice and public confidence, but that observation did not establish a legal requirement.

This was a first-instance judicial review in the Administrative Court. Permission had been granted on the papers by Nicol J on 10 October 2011. The Divisional Court dismissed the application.