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

The claim for judicial review concerned the Senior Coroner's decision not to resume an adjourned inquest into the violent or unnatural death of Ms Vittoria Baker. The court held that the investigative duty under Article 2 of the European Convention on Human Rights was engaged and that the Senior Coroner had applied an incorrect test in deciding not to resume the inquest. Paragraphs 7 and 8 of Schedule 1 to the Coroners and Justice Act 2009 require a coroner to consider whether there is sufficient reason to resume a suspended investigation; the Senior Coroner relied instead on whether the facts had been adequately aired in public. The Senior Coroner's reliance on a plea hearing together with two private internal investigations (an NHS root cause analysis and a confidential Domestic Homicide Review) did not, in the court's view, discharge the Article 2 investigative obligation. The claim was allowed and the decision not to resume the inquest was declared unlawful.

This is a judicial review by Mr Muhammad Silvera challenging the Senior Coroner for Oxfordshire's decision of 10 February 2016 not to resume the inquest into the death of his mother, Ms Vittoria Baker, who died in violent or unnatural circumstances on or about 16 August 2012. The inquest had been opened and adjourned pending a criminal investigation. The defendant coroner decided not to resume following criminal proceedings in which the defendant (Ms Baker's daughter, referred to as 'K') pleaded guilty to manslaughter on the basis of diminished responsibility and received a hospital order. Subsequent investigations included an internal Oxford Health NHS Foundation Trust root cause analysis and an Oxford Safer Communities Partnership Domestic Homicide Review under section 9 of the Domestic Violence, Crime and Victims Act 2004.

The claimant sought permission for judicial review contending that (i) the coroner applied the wrong legal test when deciding not to resume the inquest and (ii) the investigations upon which the coroner relied could not satisfy the procedural investigative duty under Article 2 ECHR. The Senior Coroner had referred to the Court of Appeal decision in R v Inner West London Coroner ex parte Dallaglio and to whether the facts of the death had been "adequately aired in public", and he treated the Crown Court plea hearing and the two investigations as collectively sufficient to satisfy Article 2.

The court examined whether Article 2 was engaged and concluded that it was. It held that the correct statutory test when considering resumption of a suspended inquest is whether there is "sufficient reason" to resume (Schedule 1, paragraphs 7 and 8, Coroners and Justice Act 2009). The Senior Coroner had applied an incorrect emphasis on whether matters had been adequately aired in public and had overstated the significance of the criminal proceedings (there was no full trial) and the private nature of the other inquiries. Drawing on authorities including R (Amin) v Secretary of State for the Home Department and Strasbourg jurisprudence cited therein, the court found that private internal investigations and a criminal plea hearing, in the circumstances of this case, were not capable of discharging the Article 2 procedural duty. The court concluded that the Senior Coroner's decision was unlawful and in breach of both Article 2 and the common law investigative duty and ordered that the claim succeed.

The judgment notes the rarity of resumption after criminal proceedings but emphasises that the statutory test is "sufficient reason" and that Article 2 requires public, independent and effective investigative processes in appropriate cases.

This is a first-instance judicial review. The court allowed the claim. The Senior Coroner's decision not to resume the inquest was unlawful because Article 2 ECHR was engaged, the coroner applied an incorrect test by focusing on whether the facts had been adequately aired in public, and the private internal investigations together with the plea hearing did not discharge the Article 2 procedural investigative obligation.