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

A coroner has broad discretion to determine the nature and extent of an inquest. The inquiry may examine matters directly or indirectly relevant to the circumstances of the death and is not confined to the final link in the chain of causation. Marginal or irrelevant evidence renders an inquest unlawful only where its admission undermines the integrity of the process.

Where the procedural obligation under article 2 is engaged, the conduct of state and non-state participants must be investigated fully and fairly where necessary to ascertain the truth. A coroner who has heard the evidence is also best placed to decide whether a verdict should be left to the jury. An appellate court will rarely interfere with that evaluative decision where it was reasonably open to the coroner.

The appellant general practitioner prescribed Heminevrin to a patient with a history of alcohol misuse, overdoses and self-harm. The patient consumed approximately 52 tablets with alcohol and died. Following a lengthy inquest, the jury returned a verdict of unlawful killing based on the prescribing of the drug.

The Divisional Court refused permission to seek judicial review of the inquest. The Court of Appeal granted permission to appeal on whether the coroner had allowed the inquiry to exceed its lawful scope. The appellant also renewed grounds concerning the exclusion of a suicide verdict, alleged bias, causation directions, the admission and exclusion of evidence, and the form of the narrative verdict.

The central issue was whether the coroner's management of the evidence and verdicts had rendered the inquest unlawful.

1. Disposition. The appeal on the permitted ground concerning the scope of the inquest was dismissed. Permission to appeal on all the additional grounds was refused. Maurice Kay LJ and Lord Dyson MR agreed with Hallett LJ.
2. A coroner must investigate the relevant facts fully, fairly and fearlessly, while retaining responsibility for setting the bounds of the inquiry and determining its procedure. The inquiry may extend beyond evidence strictly necessary for the verdict and beyond the final link in the chain of causation. The coroner has broad discretion because inquests arise from widely differing circumstances and may serve the prevention of future deaths.
3. There was no lesser standard of scrutiny for a non-state participant merely because article 2 was engaged through the involvement of state agents. Full and fair examination of each participant's role could be necessary to place the conduct of state agents in context and ascertain the truth. The appellant's prescribing, knowledge, records, credibility, previous prescribing practices and systems were therefore substantially within the legitimate scope of the inquiry.
4. Some evidence concerning a later performance review and aspects of the surgery's computer system was, at most, marginal or peripheral. Its admission did not undermine the fairness or lawfulness of the proceedings. A challenge based on excessive scope required more than a collection of minor complaints arising during a lengthy and thorough investigation.
5. The evidence concerning communications between the General Medical Council and the primary care trust was relevant to the possible prevention of future deaths and a report under rule 43 of the Coroners Rules 1984. However, a nationwide recommendation about protocols for instructing experts appeared too remote from the prevention of death. That recommendation did not affect the jury's deliberations.
6. The coroner had reasonably managed the written and expert evidence, properly directed the jury on causation and intervening acts, and acted within his discretion when framing the possible verdicts. The material disclosed neither actual nor apparent bias.
7. The coroner reasonably declined to leave suicide to the jury. Although there was evidence of previous self-harm and a recent threat, the circumstances also supported accidental consumption without suicidal intent and a subsequent attempt to obtain help. The coroner, having heard the evidence, was entitled to conclude that suicide could not safely be proved to the criminal standard. The unlawful-killing verdict also demonstrated that the jury found the prescribing to be a material cause and found no intervening act sufficiently potent to break the chain of causation.

1. Court of Appeal (Civil Division): In [2013] EWCA Civ 181, dismissed the appeal concerning the scope of the inquest and refused permission to appeal on the additional grounds.
2. Divisional Court of the Queen's Bench Division: Foskett J and HHJ Thornton QC refused permission to seek judicial review of the conduct of the inquest. No citation is stated in the judgment.