Lagos, R (on the application of) v HM Coroner for the City Of London

A coroner may return a verdict of suicide only where the deceased’s intention to die and the act causing death are proved beyond reasonable doubt. Suicide must be affirmatively proved and must not be inferred merely because it is the most probable explanation. Where accidental death cannot be excluded, an open verdict may be appropriate.

A coroner’s evaluative conclusion is reviewable only on the stringent Wednesbury standard. The court must not substitute its own assessment of the evidence. Decisions about witnesses and the scope of an inquest are also subject to that threshold, although the coroner must exercise the broad procedural discretion under the Coroners Rules 1984 fairly.

The claimant sought judicial review of an open verdict returned by the defendant coroner at the inquest into his wife’s death. The evidence made suicide the most probable explanation, but the fall was unwitnessed and the possibility of an accident could not be excluded.

The claimant alleged that the coroner should have returned a verdict of suicide, that the verdict was irrational and biased, and that the inquest was procedurally unfair because of a change of interpreter, restrictions on questioning and the admission of written evidence.

1. Verdict of suicide. Under section 11 of the Coroners Act 1988 and rules 36 and 42 of the Coroners Rules 1984, the inquest was confined to the statutory questions concerning the deceased and how, when and where she came by her death. The approach described in R v HM Coroner for North Humberside, Ex parte Jamieson [1995] QB 1 was applicable.
2. A suicide verdict required proof beyond reasonable doubt that the deceased intended to take her own life and performed an act with that intention which caused her death. Suicide was not to be presumed merely because it was likely. The principles in R v City of London Coroner, Ex parte Barber [1975] 1 WLR 1310, In Re Davis [1968] 1 QB 72, R v West London Coroner, Ex parte Gray [1988] 1 QB 467, R v Essex Coroner, Ex parte Hopper (unreported, 13 May 1988), and R (Jenkins) v HM Coroner for Bridgend and Glamorgan Valleys [2012] EWHC 3175 (Admin) supported that approach.
3. Although suicide was the most probable explanation, the evidence did not establish beyond reasonable doubt that the deceased deliberately fell. The coroner correctly directed himself and reached a conclusion open to a reasonable coroner. The court could not substitute its own view. The verdict was therefore neither irrational nor perverse.
4. The coroner’s decision as to witnesses was governed by the relevance and expediency test in section 11. It was reviewable only if unreasonable: R v HM Coroner for Western District of East Sussex, Ex parte Homberg (1994) 158 JP 357 and R (Cairns) v HM Deputy Coroner for Inner West London [2011] EWHC 2890 (Admin). The inquisitorial nature of an inquest gives the coroner a broad discretion, but that discretion must be exercised fairly: R (Coker) v HM Coroner for Inner South London [2006] EWHC 614 (Admin).
5. The change of interpreter caused no unfairness. Although the court had concerns about interruptions during questioning, they were not sufficiently serious to invalidate the inquest, and any inaccuracies in the disputed evidence would not have altered the conclusion that accident could not be excluded. Written evidence was lawfully admitted under rule 37 because the claimant had received it and did not object.
6. The bias allegation failed under the test in Porter v Magill [2002] 2 AC 357. The claim for judicial review was dismissed.