Devon & Cornwall Police v HM Coroner for Plymouth, Torbay and South Devon & Ors

An inquest jury should not be asked to make findings about alleged systemic or procedural defects without evidence capable of supporting them. A causal link between State action and death does not itself establish a breach of the substantive duty under Article 2 of the Convention. Where concerns about future risks remain, the coroner’s statutory duty to report matters capable of preventing other deaths provides an Article 2-compliant alternative. Coroners retain a broad discretion over the scope of their enquiries, but that discretion does not extend to inviting speculation. The Administrative Court may intervene during an ongoing inquest in an exceptional case, particularly where the question is legally unsustainable and delay risks requiring a second inquest.

The claimant sought judicial review of the defendant coroner’s decision to ask an inquest jury whether defects in State organisations had contributed to the deaths arising from a fatal road collision. The inquest concerned the deaths of Oisin Twomey and Marek Wojciechowski and was part heard when the application was issued.

The evidence established that police intervention preceded the collision and that the police had no procedure specifically directed to suicidal motorists. It did not establish that a separate procedure was required, that existing procedures were deficient, or that another procedure would have been better. The central issue was whether question 9 could lawfully be left to the jury.

1. Application granted and decision quashed. The coroner’s proposed question 9 could not properly be left to the jury.
2. Under section 5 of the Coroners and Justice Act 2009, the purpose of an inquest is confined to identifying the deceased and ascertaining how, when and where the death occurred, with the circumstances expanded where necessary to avoid a breach of Convention rights. The jury cannot express opinions outside those statutory matters, subject to paragraph 7 of Schedule 5.
3. Article 2 may be engaged by a systemic failure to provide reasonably necessary procedures or by a real and immediate risk to life coupled with a reprehensible failure by State agents to use available powers. However, an act or omission which causes or contributes to a death does not, without more, establish a breach of the substantive Article 2 obligation.
4. The scope of an inquest is generally within the coroner’s broad discretion. Nevertheless, inquest procedure must be evidence-based. A jury must not be invited to decide that procedures for vulnerable or suicidal motorists were defective when there is no evidence that different procedures were required or would have been appropriate. The fact that the police intervention contributed causally to the collision, and that other options might have existed, was insufficient.
5. The duty under paragraph 7(1) of Schedule 5 to the Coroners and Justice Act 2009 is mandatory where the investigation gives rise to concern about circumstances creating a future risk of death. That duty is an integral part of the Article 2-compliant procedure and does not depend on proof that the circumstances already caused a death or breached Article 2.
6. Although intervention during a continuing inquest is exceptional, permission was justified because the expedited hearing avoided the risk of a second inquest, the question was clearly unlawful, and an affirmative answer could materially prejudice a police officer who had not had a proper evidential opportunity to answer the criticism. The court did not determine the separate challenges to the coroner’s reasons or to the Galbraith standard of proof.

This was a first-instance judicial review application. The claim was issued on 20 November 2013, permission was directed to an oral hearing, and the matter proceeded as a rolled-up hearing during the ongoing inquest.