Shafi v HM Senior Coroner for East London

A coroner investigating a death overseas must make all reasonable efforts to obtain sufficient relevant evidence, particularly where the death occurred in custody. The coroner may proceed when sufficient information is available or further requests are unlikely to produce useful evidence, provided that doing so is in the interests of justice and the discretion is exercised fairly after considering interested persons’ submissions.

Written evidence from overseas witnesses should not be admitted merely because personal attendance appears unlikely. The coroner should consider attendance in person, by video link or by another suitable live link before relying on written evidence. Deaths in custody overseas do not automatically require a jury under the mandatory provisions of the Coroners and Justice Act 2009.

Doris Shafi applied under section 13 of the Coroners Act 1988 to quash the inquest into the death of her son, Lee Bradley Brown, who died in custody in Dubai. The inquest returned an open conclusion, recording the medical cause of death as unascertained.

She alleged insufficiency of inquiry in obtaining evidence, calling witnesses and questioning them, and irregularity arising from the admission of written evidence and the absence of a jury. The central issues were whether the coroner had made sufficient efforts to obtain overseas evidence, whether evidence from Dubai was admissible in writing, and whether a jury was mandatory.

1. Fresh inquest. The court quashed the conclusions of the inquest and ordered a fresh investigation and inquest. There had been insufficiency of inquiry concerning the Dubai evidence.
2. Obtaining overseas evidence. A coroner must make all reasonable efforts to obtain sufficient relevant evidence. The coroner has no power to investigate overseas, compel foreign witnesses to attend, or require disclosure by a foreign state. The decision when to proceed is a judicial discretion. An inquest may proceed when sufficient information is available or further requests are unlikely to be productive, provided that proceeding is in the interests of justice and the decision is made fairly after assessing all available information and the submissions of interested persons, especially the family.
3. Written evidence and live links. The word attend in Rule 23(1)(b) and (c) of the Coroners (Inquests) Rules 2013 is not confined to attendance in person. It may include attendance by video link or another suitable video or audio link. Before admitting written evidence from Dubai, the coroner should have explored attendance by the relevant witnesses in person or by video link. The absence of evidence of a violent death did not resolve the unexplained medical and mechanical causes of death. Admission of the written Dubai evidence without further inquiry was therefore a significant failure in due process.
4. Jury. Section 7(2)(a) of the Coroners and Justice Act 2009 does not require a jury in every case of a death in custody abroad. The statutory reference to a person dying in custody or otherwise in state detention has the same meaning in sections 1(2) and 7. The mandatory duty to investigate a death in custody overseas arises only where the coroner has reason to suspect a violent or unnatural death or that the cause of death is unknown. The court did not determine whether a jury should be summoned under section 7(3); that was left to the new coroner.
5. Pre-inquest review. A pre-inquest review hearing should usually be held in cases involving complexity or difficulty. Deaths in custody, other than straightforward natural deaths, and deaths overseas involving evidence, disclosure, scope, timing or jury issues will generally require one. Failure to hold a review was not itself an irregularity in this case.