Mays v HM Senior Coroner for Kingston Upon Hull & East Riding of Yorkshire

Under section 13 of the Coroners Act 1988, a fresh inquest may be ordered where new evidence may reasonably show that the substantial truth about how a person died was not revealed at the original inquest. A different conclusion need not be likely. The interests of justice may require a fresh inquest where the evidence is materially incomplete, particularly in an Article 2 investigation, and where independent public scrutiny has not established relevant facts. The court may order a proportionate further inquest focused on the new evidence, but the conduct and scope of that inquest remain matters for the coroner.

Sally Mays died after she was refused psychiatric admission and later took an overdose and asphyxiated herself. Her parents applied, with the Attorney-General’s fiat, under section 13 of the Coroners Act 1988 to quash the original inquest and obtain a fresh investigation and inquest.

After the inquest, evidence emerged of a previously undisclosed conversation between a community psychiatric nurse and a consultant psychiatrist shortly after the refusal of admission. The conversation had not been independently investigated and might reveal a further opportunity to prevent Sally’s death. The issues were whether the new evidence made a fresh inquest necessary or desirable in the interests of justice, and whether the original investigation discharged the State’s Article 2 obligations.

1. The court allowed the application, quashed the original inquest and ordered a fresh investigation and inquest under section 13 of the Coroners Act 1988.

2. The statutory question is whether the interests of justice make a further inquest necessary or desirable. Fresh evidence that may reasonably lead to the conclusion that the substantial truth about the circumstances of death was not revealed will normally satisfy that test. A fresh inquest does not require a likely different verdict. Even evidence likely to confirm the original conclusion may justify a fresh inquest where public disclosure and scrutiny are important.

3. The undisclosed car-park conversation was relevant and potentially highly material. Its factual content had not been established by any independent public investigation. It might disclose a further opportunity for intervention and could lead to additional findings of fact, notwithstanding that the original conclusions were unlikely to change substantially.

4. The original inquest was an Article 2 inquest because there was an arguable breach of the direct operational duty to protect life. Applying the requirements described in Jordan v United Kingdom [2001] EHRR 52, as endorsed in R (on the Application of Amin) v Secretary of State for the Home Department [2003] UKHL 51, the investigation had not yet been effective or sufficiently public in relation to the new evidence. No independent process had established the relevant facts, and the family had not been involved in an investigation addressing them.

5. The wishes of the bereaved family were relevant to desirability and had to be balanced against resources and time. A proportionate fresh inquest could use the earlier transcript as documentary evidence under Rule 23 of the Coroners (Inquests) Rules 2013, but the precise conduct of the further investigation remained for the Senior Coroner.