McDonnell v HM Assistant Coroner for West London

A coroner conducting a non-Article 2 inquest must focus on the immediate circumstances and means of death. The determination must be factual, brief and non-judgmental, and must not apportion civil or criminal responsibility. A decision about the scope of inquiry or witnesses is reviewable only for irrationality. On a statutory challenge, the court may order a new inquest where this is necessary or desirable in the interests of justice, but the mere possibility that another coroner might assess complex medical evidence differently is insufficient. The court must consider the shortcomings in the original inquest, the possibility of a different outcome and any need to investigate new evidence.

The claimant, the widow of the deceased, sought an order under section 13 of the Coroners Act 1988 quashing the determination at an inquest and requiring a fresh inquest before a different coroner. The inquest concluded that the deceased died from a fatal cardiac arrhythmia triggered by a vaso-vagal event in the presence of excessive codeine and prescribed medication, and recorded the conclusion as misadventure.

The claimant challenged the coroner’s treatment of the codeine evidence, the prescribing of citalopram with other medication, the absence of an ECG, and the way those matters were recorded. The central questions were whether the coroner was entitled to reach her conclusions and whether any defect made a further inquest necessary or desirable in the interests of justice.

1. Application dismissed. The inquest was a conventional Jamieson inquest, not an Article 2 Middleton inquest. Its purpose was to establish who the deceased was and how, when and where he came by his death. The coroner was prohibited from determining criminal or civil liability and was required to keep the determination factual and non-judgmental under the Coroners and Justice Act 2009.
2. The section 13 review proceeded on the same basis as judicial review. The claimant had to show that the coroner’s decision was Wednesbury unreasonable or irrational. Decisions about the scope of inquiry and the witnesses to be called were matters of judgment and were reviewable only on that demanding basis.
3. The coroner was entitled to conclude that codeine contributed to the death. There was evidence that an excessive quantity had been taken and that codeine might have contributed to abdominal distension, nausea and a vaso-vagal event capable of triggering fatal arrhythmia. The evidence did not require the coroner to find that codeine was the primary or directly cardio-toxic cause. The conclusion of misadventure was therefore open to her.
4. The coroner had investigated the prescribing issues and was not required to include every underlying cause or alleged missed opportunity in the Record of Inquest. A brief reference to contraindicated medication might have been appropriate, but it would have been difficult to express neutrally and within the proper scope of a Jamieson inquest. The record accurately stated that advice to obtain an ECG had been given repeatedly and not taken up. The coroner was entitled to conclude that the doctors had balanced the risks of continuing the higher dose against the risk of the deceased disengaging from treatment.
5. The interests-of-justice jurisdiction did not justify a fresh inquest. The possibility that another coroner might take a different view of disputed medical evidence was insufficient. The matters relied on had been investigated, no new evidence was advanced, and the existing Regulation 28 report addressed the systemic issue identified.