Lesley Ann Davison v HM Senior Coroner for Hertfordshire

Under section 13 of the Coroners Act 1988, a fresh inquest may be ordered where new evidence makes a further investigation necessary or desirable in the interests of justice. A different verdict need not be likely. Fresh evidence may justify a new investigation where it materially enlarges the inquiry, casts existing evidence in a different light, or raises substantial questions about care and the prevention of future deaths. Procedural irregularities, including failure to comply with rule 23 of the Coroners (Inquests) Rules 2013, must be assessed in the context of the new evidence and its effect on the fairness and sufficiency of the original inquiry. A coroner acting neutrally in section 13 proceedings will ordinarily not be liable for costs unless the circumstances justify that order.

The claimant, the mother of Megan Davison, applied with the fiat of the Attorney General under section 13 of the Coroners Act 1988. Megan had died by suicide after suffering from Type 1 diabetes and diabulimia. At the inquest, the coroner admitted parts of a written statement from a treating therapist without informing interested persons of their right to object under rule 23 of the Coroners (Inquests) Rules 2013. The coroner concluded suicide and made no prevention of future deaths report.

New expert evidence stated that diabulimia was more widespread than the coroner had understood, identified possible deficiencies in Megan’s care, and raised systemic concerns. The issues were whether a fresh investigation was necessary or desirable in the interests of justice, whether article 2 was engaged, and whether the coroner should pay the claimant’s costs.

1. Fresh investigation. The application succeeded under section 13(1)(b) of the Coroners Act 1988. The new expert evidence showed that diabulimia was more widespread than had been understood, identified possible deficiencies in care, and raised questions about whether inadequate care contributed to Megan’s death. It therefore added important information and cast the existing evidence in a different light. A fresh investigation was necessary or desirable in the interests of justice.
2. The court accepted that the new evidence made it possible that a fresh inquest would lead to a prevention of future deaths report, a different view about whether care contributed to the death, and a fuller narrative conclusion. The coroner had not been required on the original evidence to seek out evidence supporting such a report. The decision whether to make one would belong to the coroner conducting the fresh investigation under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009.
3. The coroner had erred by failing to inform interested persons of their right to object to written evidence under rule 23. In light of the new evidence, the family’s wish to question the treating therapist became materially more significant. It was unnecessary to decide whether an objection operated as a veto or merely as a factor for the coroner to consider.
4. The medical cause of death was unlikely to change, and that ground did not independently justify a fresh investigation. On the evidence before the original coroner, article 2 was not engaged. The carers were obliged to respect Megan’s autonomy and had no control over her conduct in the community. Applying the approach in R (Maguire) v Blackpool and Fylde Coroner, there was no sufficient link between state control and the risk of suicide to generate an operational duty.
5. The original conclusion was quashed and a fresh investigation was directed before a different coroner. The claimant’s costs application was refused. The coroner had reasonably adopted a neutral stance, and his participation did not make him an active party.

First-instance application under section 13 of the Coroners Act 1988. The court quashed the coroner’s conclusion and directed a fresh investigation by a different coroner.