Joy Dove v HM Assistant Coroner for Teesside and Hartlepool & Anor

A fresh inquest under Coroners Act 1988, section 13 may be desirable where fresh expert evidence could enable findings about a material contribution to a deceased’s mental state and a brief, neutral narrative conclusion. A different short-form conclusion need not be likely.

A non-Article 2 inquest may investigate psychiatric, as well as physical, factors which may have contributed to death. It must remain directed to factual findings and cannot become an inquiry into blame or civil liability. An Article 2 operational duty requires, among other matters, a real and immediate risk to life known or constructively known to the state and a sufficient assumption of responsibility. General administration of welfare benefits does not itself satisfy those requirements.

Jodey Whiting died from an overdose in February 2017. The original inquest recorded suicide. Her mother later obtained an Independent Case Examiner’s report identifying serious failures in the handling of Ms Whiting’s employment and support allowance, and a psychiatric report addressing the likely effect of the abrupt withdrawal of benefits upon her mental state.

With the Attorney General’s fiat, her mother sought a fresh inquest under section 13 of the Coroners Act 1988. The Divisional Court dismissed the application: [2021] EWHC 2511 (Admin). On appeal, the issues were whether the fresh evidence made a new ordinary inquest necessary or desirable, and whether the Department owed an Article 2 operational duty.

1. Appeal allowed on ground 1. A fresh Jamieson inquest was desirable in the interests of justice under section 13 of the Coroners Act 1988. The psychiatric evidence was materially different from the family’s evidence at the first inquest. It could support factual findings that the abrupt withdrawal of benefits contributed to a deterioration in the deceased’s mental health and, if accepted, a brief neutral narrative conclusion.

2. The Divisional Court erred by treating the deterioration in mental health as distinct from death by suicide, and by approaching causation as though a but-for cause of death were required. In an inquest, conduct is causative if, on the balance of probabilities, it made a more than minimal, negligible or trivial contribution. A coroner may investigate factors contributing to mental deterioration which led to suicide. There is no principled distinction between physical and psychiatric contributory factors.

3. The renewed inquest is not to investigate or determine the Department’s individual policy failures. Those matters remain outside the proper scope of an ordinary inquest. The Independent Case Examiner’s report may, however, provide background evidence establishing the relevant sequence of events and that benefits should not have been stopped. Any conclusion must comply with sections 5(3) and 10(2) of the Coroners and Justice Act 2009 and remain brief, factual and non-judgmental.

4. A different verdict was not a precondition to a fresh inquest. The potential importance of determining the substantial truth, the public interest, and the possibility of a preventing future deaths report made a further inquest desirable.

5. Ground 2 dismissed. The Department owed no Article 2 operational duty. Although the deceased was vulnerable, the evidence did not show that the Department knew or ought to have known of a real and immediate risk of suicide at the material time. Nor did administering welfare benefits amount to an assumption of responsibility for protecting her from suicide. A fresh Article 2 inquest was therefore not required.

Whipple LJ gave the principal judgment. Lewis LJ and William Davis LJ agreed. A fresh ordinary inquest was directed before a different coroner.

• Court of Appeal (Civil Division): Allowed the appeal on the fresh-evidence ground and directed a fresh ordinary inquest before a different coroner; dismissed the Article 2 ground: [2023] EWCA Civ 289.
• High Court, Divisional Court: Refused the application under section 13 of the Coroners Act 1988 for a fresh inquest: [2021] EWHC 2511 (Admin).