Jones v HM Coroner for Gwent & Anor

The power to order a fresh inquest under section 13 of the Coroners Act 1988 is broad, but it is directed to defects affecting the integrity of the inquest or the proper consideration of relevant evidence. It is not an alternative form of judicial review whenever a coroner may have made an error of law or reached a conclusion arguably contrary to the evidence. A change in prosecutorial opinion is not, without more, a new fact or fresh evidence and does not establish that the original verdict was improperly reached. Delay and the need for finality may independently make reopening contrary to the interests of justice.

The claimant applied, with the Attorney-General’s consent, under section 13 of the Coroners Act 1988 for the original inquest into the death of his five-year-old son to be quashed and a fresh inquest ordered. The coroner had recorded a narrative verdict following an E. coli outbreak and had rejected unlawful killing because he was not satisfied that a reasonably prudent person would have foreseen a serious and obvious risk of death.

The Director of Public Prosecutions later accepted that the earlier decision not to prosecute for gross negligence manslaughter had been erroneous, but also considered that prosecution was by then barred as an abuse of process. The central issue was whether that change of prosecutorial position, or the alleged legal error in the verdict, engaged section 13.

1. The application was refused. Section 13 gives the High Court a broad discretion, and the listed grounds are not exhaustive. However, the relevant defect must ordinarily cast doubt on the integrity of the proceedings or raise concern that the verdict was reached without proper consideration of all relevant evidence.
2. The statutory power cannot generally be used to pursue a judicial review challenge long out of time. It is not enough to allege that the coroner reached a conclusion which was not properly open to him on the evidence. Such a challenge could have been brought promptly by judicial review, although its prospects of success were not determined.
3. The later opinion of leading counsel, and the DPP’s acceptance that the CPS had made an error, did not constitute a new fact or fresh evidence. They did not alter the factual basis before the coroner and would not themselves have been admissible evidence at the inquest. Nor did the DPP’s changed view demonstrate that the coroner’s conclusion, reached on the criminal standard of proof, was improper.
4. The court rejected the suggested broad reading of Re Tabarn and R v Divine ex parte Walton. Those authorities concerned defects in the process or the coroner’s lack of material facts, not every arguable error in applying the law.
5. In any event, reopening would not have been in the interests of justice. The application followed very substantial delay, finality was important, and the existing narrative verdict accurately reflected the facts while recommendations had already been made to prevent similar deaths. This was a secondary ground; the application would have failed even if brought sooner.