Silvera, R (on the application of) v HM Senior Coroner for Oxfordshire

A suspended inquest may be resumed where the senior coroner considers there is sufficient reason to do so. The statutory test is not whether the facts of the death have already been adequately aired in public. The discretion is broad, but it is not limited by any requirement for exceptional circumstances.

Where the investigative duty under article 2 of the Convention is engaged, criminal proceedings and internal investigations will not necessarily discharge it. The investigation must meet minimum standards of independence, effectiveness and public scrutiny, with an appropriate opportunity for the deceased’s family to participate. A plea and hospital order directed principally to the offender’s responsibility, together with private internal reviews, did not satisfy those requirements.

The claimant sought judicial review of the Senior Coroner for Oxfordshire’s decision not to resume an inquest into his mother’s violent or unnatural death. The inquest had been suspended while criminal proceedings were considered. The claimant’s sister later pleaded guilty to manslaughter on grounds of diminished responsibility and received a hospital order. She subsequently died.

The coroner relied on the criminal proceedings, an internal NHS investigation and a domestic homicide review. The claimant argued that the coroner had applied the wrong statutory test and that the investigations did not satisfy the investigative duty under article 2 of the Convention or the common law. The central issues were whether there was sufficient reason to resume the inquest and whether the existing investigations were adequate.

1. The claim was allowed. The Senior Coroner’s decision not to resume the inquest was unlawful and breached both article 2 of the Convention and the common-law duty to investigate the death fully.
2. Paragraph 8 of Schedule 1 to the Coroners and Justice Act 2009 requires a suspended investigation to be resumed where the senior coroner thinks there is sufficient reason to resume it. The correct question was not whether the facts of the death had already been adequately aired in public. The discretion is highly discretionary, but it is not confined by a requirement for exceptional circumstances. The court applied the approach in R. v. Inner West London Coroner, ex parte Dallaglio and another [1994] 4 All ER 139.
3. On the facts, the investigative duty under article 2 was clearly engaged. The court relied particularly on R. (Amin) v. Secretary of State for the Home Department [2004] 1 AC 653, which recognised that the form of investigation may be flexible but that minimum standards must be met. The investigation must be capable of bringing the material facts to light, exposing culpable or discreditable conduct, and identifying dangerous practices, with suitable independence, public scrutiny and family participation.
4. The criminal proceedings did not amount to a Crown Court trial. An acceptable plea had been tendered, and the proceedings focused on the sister’s responsibility for the killing. They did not examine the wider circumstances or the possible failures of public authorities. The NHS investigation was internal and private. The domestic homicide review was also private and confidential, despite its broader family involvement.
5. Taken together, those proceedings and investigations did not discharge the article 2 obligation. The inquest should therefore have been resumed.

The judgment was a first-instance judicial review of the Senior Coroner’s decision dated 10 February 2016. The inquest had previously been suspended pending criminal proceedings, and the Senior Coroner had declined to resume it.