Worthington, R (On the Application Of) v The Mother of Poppi Worthington & Ors

In a non-Middleton inquest, the statutory question of how the deceased came by the death is not confined to the medical cause of death. The coroner has judgment, subject to the statutory limits, to decide which findings of fact are sufficiently important to explain the means of death and should be included in the determination. A fact which did not itself cause death may properly be recorded where it forms part of the immediate factual matrix explaining the fatal circumstances. The court should be cautious about micromanaging inquests or striking out accurate, neutral and unchallengeable factual references. A tribunal that states it will remain neutral in judicial review proceedings must confine its submissions to that stance; it cannot rely on neutrality to avoid the ordinary costs consequences of partisan advocacy.

An infant died after suffering anal injuries and subsequently being placed in an unsafe sleeping environment. Following earlier family proceedings and a fresh inquest, the senior coroner found that the child had been anally penetrated, but that the penetration had not caused or contributed to death. He recorded the penetration in his reasoning on the possible conclusions and in Box 3 of the Record of Inquest, while concluding that death resulted from asphyxia caused by the unsafe sleeping environment.

The child’s father accepted the factual findings but sought judicial review and removal of the references to anal penetration. The central issue was whether those references exceeded the permissible scope of a determination under sections 5 and 10 of the Coroners and Justice Act 2009.

1. The claim was dismissed. The references to anal penetration in the coroner’s reasoning and in Box 3 of the Record of Inquest were lawful.
2. Section 5 of the Coroners and Justice Act 2009 distinguishes between the purpose of the investigation, the findings of fact, the determination of how the deceased came by the death, and the conclusion. The Chief Coroner’s Guidance identifies a three-stage process: findings of fact; distilling from those findings how the deceased came by the death; and recording a conclusion consistent with them.
3. In a non-Article 2, or Jamieson, inquest, “how” is narrower than the circumstances inquiry required in a Middleton inquest, but it is not confined to the medical cause of death. It may include facts and acts or omissions directly responsible for, or sufficiently explanatory of, the means of death.
4. The statutory restrictions do not prevent a coroner from recording a negative conclusion, including that an act suggested as causative did not cause death. Here, the penetration explained why the child was in the unsafe sleeping environment that caused death. Its inclusion was therefore appropriate and did not express an impermissible opinion under section 5(3), nor determine civil or criminal liability contrary to section 10(2).
5. The court should not micromanage an inquest. It should be cautious before striking out accurate, neutral and unchallengeable findings which the coroner reasonably considers necessary to explain the means of death.
6. The coroner was entitled to the usual costs order. Although he stated that he would assist neutrally, his written and oral submissions sought to persuade the court against the claim. The claimant was ordered to pay the coroner’s costs, subject to the legally aided claimant’s means-assessment proviso under section 26(1) of the Legal Aid, Sentencing and Punishment of Offenders Act 2012. The court cautioned tribunals against claiming neutrality while making partisan submissions.

This was a first-instance judicial review in the Administrative Court. The judgment states that an earlier decision of this court had quashed the first record of inquest and ordered a new inquest, but no citation for that decision is provided.