Rushbrooke v HM Coroner for West London

Under section 13 of the Coroners Act 1988, the question is whether the interests of justice make a further investigation and inquest necessary or desirable. That question may be answered affirmatively where procedural irregularities, an insufficient inquiry, rejection of relevant evidence, or the emergence of material information creates a real possibility of a different outcome. In such circumstances the High Court may quash the existing determination and order a fresh investigation and inquest.

The applicant, the daughter and relevant person’s representative of the deceased, applied with the Attorney General’s authority under section 13 of the Coroners Act 1988. The application challenged a paper inquest into her mother’s death, which had concluded that the death resulted from natural causes.

The applicant alleged inadequate notice and participation, persistent interruption, failure to investigate unexplained fractures, failure to consider whether those fractures contributed to death, rejection of relevant evidence, and failure to await a safeguarding investigation. The respondent accepted that a fresh inquest might produce an alternative outcome. The central issue was whether the interests of justice made a further investigation and inquest necessary or desirable.

1. The application was granted. The court quashed the determination made at the inquest held on 27 October 2016 and ordered a fresh investigation and inquest. The respondent was ordered to pay the applicant’s costs of £750.
2. Section 13 of the Coroners Act 1988 requires the High Court to determine whether, in the interests of justice, a further inquest or investigation is necessary or desirable. The court adopted that formulation from Attorney General v HM Coroner of South Yorkshire (West) [2012] EWHC 3783 (Admin).
3. The interests-of-justice threshold was satisfied. The inquest was affected by alleged procedural irregularities, including inadequate notice and an inability properly to make representations. More importantly, the investigation and inquiry were insufficient. The unexplained fractures, their possible contribution to the death, the asserted cause of death involving a stroke, and the safeguarding investigation required proper consideration.
4. The respondent’s acceptance that a fresh investigation and inquest might produce an alternative outcome supported the conclusion that a new process was clearly necessary and desirable in the interests of justice. Lord Justice Hickinbottom made the order, and Mr Justice Garnham agreed.