ZAMZAM ARAB TURE (R on the application of) v HER MAJESTY’S SENIOR CORONER FOR MANCHESTER NORTH

Judicial review of a coroner’s inquest is supervisory. The court must not substitute its own assessment of the evidence or case management for that of the coroner. A coroner must investigate fully, fairly and fearlessly, but may set reasonable and fair limits to the inquiry and decide which witnesses and evidence are required. Intervention requires an arguable public law error with a realistic prospect of success, involving unlawfulness, unreasonableness or unfairness. The inquest’s findings and reasons must be assessed as a whole and in their evidential and procedural context. The absence of a material witness does not, by itself, require an expanded investigation or additional witnesses where the coroner has dealt properly with the available evidence.

The claimant sought judicial review of the senior coroner’s conclusion that her 12-year-old daughter’s drowning was accidental. The claimant alleged failures concerning the scope of the inquiry, the investigation and calling of witnesses, the adequacy of reasons, and the evidential basis for the conclusions, including the failure to conclude unlawful killing. Permission had previously been refused on the papers by Robin Knowles J on 20 May 2021. The claimant renewed the application and sought permission to amend the grounds and rely on further material. The central issue was whether any proposed ground disclosed an arguable public law error with a realistic prospect of success.

1. The renewed application for permission to seek judicial review was refused, as was permission to amend the grounds and rely on the further material. No costs or remittal order of material significance was identified.

2. Judicial review is a supervisory jurisdiction. The court does not step into the coroner’s shoes or substitute its own judgment. The relevant standards are lawfulness, reasonableness and fairness.

3. Coroner’s proceedings are inquisitorial. The coroner must investigate fully, fairly and fearlessly, but must also be allowed to set the bounds of the inquiry and make reasonable and fair case-management decisions, including decisions about witnesses and further evidence.

4. The court must read the coroner’s findings and conclusion as a whole. Individual documents or passages relied on in judicial review proceedings are pieces of a wider evidential and procedural picture. The fact that material could be viewed differently does not establish a reviewable error.

5. The coroner had considered the evidence concerning alleged bullying, planning and pushing, had made reasoned scope and witness decisions, and had kept the scope of the inquiry under review. Those decisions were lawful, reasonable and fair. There was no realistic prospect of establishing that further investigation or oral evidence from the additional children was required.

6. The unavailability of Child 1 as an oral witness did not deprive the findings of an evidential basis. The coroner had carefully addressed the available ABE interview and the differing accounts given by Child 1 and others. It was not arguable that this circumstance required the coroner to enlarge the investigation or call further witnesses.

7. Arguments concerning a hypothetical absence of difference and delay in seeking amendment did not arise once the grounds were found not viable. The court nevertheless indicated that it would have been reluctant to reject a viable challenge solely because of the timing of its amendment.

• High Court (Administrative Court): The renewed application for permission for judicial review was refused. Permission to amend the grounds was also refused.
• Decision on the papers: Robin Knowles J refused permission on 20 May 2021.