Fatmire Gorani, R (on the application of) v Her Majesty’s Assistant Coroner for Inner West London

An inquest is an inquisitorial investigation for which the coroner is responsible. Even where Article 2 requires an enhanced inquest, the coroner need investigate only the issues identified as engaging the Convention obligation, not every issue raised by an interested person. The coroner must determine probable causes of death; a possible cause may be considered but need not be recorded as causative.

A reviewing court should not interfere with factual conclusions or the weight given to relevant evidence unless the decision is irrational or involves a material, objectively established error of fact. The duty to make a preventing-future-deaths report under Schedule 5 to the Coroners and Justice Act 2009 is conditioned on the coroner’s opinion that preventive action should be taken. Interested persons have no right to make submissions before that opinion is formed.

The claimant challenged the conduct and conclusions of an inquest into her husband’s suicide. The coroner initially ruled that Article 2 was not engaged, but later accepted that an alleged failure to clinically triage a call to a mental-health service arguably engaged the state’s systems duty and treated the inquest as an Article 2 inquest.

The claimant alleged apparent bias, procedural unfairness, an inadequate Article 2 investigation, failures to comply with the common-law and statutory investigative duties, factual error, irrationality, and unlawful failure to issue a preventing-future-deaths report. The central issues were the scope of the Article 2 inquiry, the causation standard applicable at an inquest, the review of factual findings, and whether prior submissions were mandatory.

1. Application dismissed. The coroner’s interventions during questioning were legitimate case management within an inquisitorial process. She was entitled to form provisional views, test evidence, summarise answers, maintain relevance and prevent repetition. The fair-minded and informed observer would not conclude that there was a real possibility of bias.
2. The declaration that the inquest was an Article 2 inquest did not require every aspect of the death to be investigated to Article 2 standards. Under section 5(2) of the Coroners and Justice Act 2009, the scope was delimited by the coroner’s ruling as to the issue requiring Convention-compliant investigation. Here that issue was the alleged systems failure on 12 December 2018.
3. The Article 2 procedural requirements identified in Jordan v UK were met. The investigation was independent, effective, reasonably prompt and public, and the next of kin were involved and represented. The coroner was not required to investigate every peripheral issue raised by the claimant.
4. Under R (Lewis) v HM Coroner for Mid and North Shropshire, a coroner must determine probable causes of death. She has power, but no duty, to record a possible cause. The coroner was therefore not obliged to determine whether the GP’s later failures possibly caused the death, although she considered those events.
5. The alleged factual errors amounted to disagreement with the inferences drawn. The findings were supported by the evidence. A reviewing court must distinguish identifying relevant considerations from reassessing the weight assigned to them; the latter remains for the decision-maker unless the conclusion is irrational.
6. Schedule 5 to the Coroners and Justice Act 2009 makes a preventing-future-deaths report mandatory only where the coroner forms the opinion that action should be taken. It imposes no requirement to hear submissions from interested persons before deciding whether that opinion is formed. The decision not to issue a report was reasonable.