Brown v HM Coroner for the County of Norfolk & Anor

An inquest may be quashed and a fresh investigation ordered where materially inaccurate public findings resulted from significant investigative failures, even though a fresh inquest may reach the same verdict. The question is whether a further investigation is in the interests of justice. That requirement may be met where material evidence was unavailable to the coroner and the existing findings are known to be inaccurate. Coroners should conduct pre-inquest review hearings transparently, provide sufficient notice and disclosure, avoid any appearance that conclusions are predetermined, and ensure that dealings with interested persons do not suggest bias or favouritism.

The claimant, the step-father of Joanne Foreman, applied with the Attorney General’s authority under section 13(1)(b) of the Coroners Act 1988 to quash the inquest into her death and require a fresh investigation. The original inquest recorded that it was not possible to reach a safe and reliable conclusion as to how she died, while excluding suicide and unlawful killing and treating insulin ingestion with alcohol as a possible cause.

It was common ground that the police investigation had been inadequate. In particular, relevant paramedic blood-glucose evidence had not been provided to the coroner, and subsequent expert evidence substantially undermined the insulin hypothesis. The central issue was whether, in those circumstances, a fresh investigation was in the interests of justice.

1. Application granted. The inquest and inquisition were quashed, and a fresh investigation and inquest were ordered before the current Senior Coroner for Norfolk or an appropriate nominated coroner.
2. Per Lord Justice Pitchford, the police investigation had been inadequate, leaving the evidence before the coroner incomplete and inaccurate in a material respect. The paramedic blood-glucose reading was significant because the later preponderance of expert evidence indicated that insulin could not have played a significant role. It was therefore in the interests of justice to hold a fresh investigation, even though its verdict might not differ. Leaving public findings known to be materially inaccurate amounted, on the facts, to a denial of justice.
3. The court rejected the claimant’s allegations of collusion, conspiracy, dishonesty and deliberate manipulation as unsupported. The investigative failures were attributed to an early and mistaken judgment that the death was not suspicious, rather than misconduct.
4. The claimant should have access to the evidence gathered during the reinvestigation, subject to ordinary public-interest-immunity considerations. The scope of questioning at the fresh inquest remained for the coroner, whose rulings the claimant must follow.
5. In additional guidance, His Honour Judge Thornton QC stated that, under rules 6 and 26 of the Coroners (Inquests) Rules 2013, pre-inquest review hearings should be properly recorded and managed. Coroners should provide an agenda, adequate notice and disclosure, avoid suggesting that conclusions are predetermined, and conduct communications so that interested persons do not reasonably perceive bias or that their interests are secondary.