Bilski (R on the application of) v HM Coroner for Inner West London

In an inquest, the questions of how, when and where a deceased came by their death are directed to the immediate circumstances of death. Earlier medical history is background unless it explains those circumstances. A record of inquisition is not unlawful because an entry is technically imperfect where the relevant information is clear from the record as a whole. An adjournment for further expert evidence is unnecessary where the proposed evidence concerns matters outside the defined scope of the inquest and the existing evidence is sufficient to determine the cause of death.

The claimant sought renewed permission for judicial review of decisions made during an inquest into the death of Evalina Bilska. The challenges concerned the Coroner’s refusal to adjourn the inquest to obtain evidence from a vascular neurosurgeon and the wording of Box 3 of the Record of Inquisition.

The deceased had been diagnosed with a carotid aneurysm approximately one month before dying from a sub-arachnoid haemorrhage caused by rupture of that aneurysm. The claimant argued that Box 3 unlawfully failed to explain how she died and that further specialist evidence was required.

1. Permission refused. Neither ground of judicial review was arguable.
2. The scope of the inquest was confined to how, when and where the deceased came by her death. Those questions concerned the immediate circumstances surrounding the death on 13 March 2016. The earlier attendance at hospital and diagnosis of an incidental aneurysm formed part of the background and did not itself explain how, when or where the deceased came by her death.
3. The Record of Inquisition contained the relevant information. The cause of death was recorded as a sub-arachnoid haemorrhage, described as an intracerebral haematoma, with rupture of the carotid aneurysm identified in Box 3. Any imperfection in the drafting of Box 3 was technical. It did not constitute a fundamental defect, vitiate the record or make it unlawful.
4. A further adjournment to obtain evidence from a vascular neurosurgeon was unnecessary. Such evidence would have been relevant only if the earlier aneurysm had formed part of the legally relevant answer to how the deceased came by her death. The Coroner had sufficient expert evidence on the issue that fell within the inquest’s scope, namely the cause of death in March 2016. The existing expert, although not a vascular neurosurgical specialist, was an appropriate witness for that issue.

• High Court, Administrative Court: Heather Williams J previously refused permission for judicial review. On renewal, Mrs Justice Whipple refused permission on both grounds.