Mid and West Wales Fire & Rescue Service, R (on the application of) v HM Acting Senior Coroner for Pembrokeshire and Carmarthenshire

A coroner should generally rely on the findings and conclusions of an independent Accident Investigation Branch unless there is credible evidence that its investigation was incomplete, flawed or deficient. The question concerns the investigation as a whole, rather than isolated conclusions. If the threshold is met, the coroner must investigate de novo; otherwise the report should not be reopened or selectively dissected. Fairness and natural justice do not create an exception where the affected party had an opportunity to make representations during the expert investigation. The threshold is high: disagreement with conclusions, hindsight criticism, better wording or a possible error will not ordinarily suffice.

A firefighter died when two fire-service boats collided during a training exercise. The Marine Accident Investigation Branch investigated and issued a report containing conclusions concerning the accident and the Claimant’s systems and procedures.

The senior coroner ruled that the report’s findings and conclusions concerning causation should be treated as conclusive evidence and could not be challenged by cross-examination at the inquest. The Claimant sought judicial review on seven grounds, including alleged unfairness, application of the wrong threshold, errors concerning regulatory standards, and failures to engage with its submissions. The central issues were the proper application of the Norfolk approach and whether the report or investigation was shown by credible evidence to be incomplete, flawed or deficient.

1. Claim dismissed. The approach established in R (Secretary of State) v HM Senior Coroner for Norfolk and confirmed in HM Senior Coroner for West Sussex v Chief Constable of Sussex Police was authoritative and was not obiter or optional.
2. The coroner should rely on an Accident Investigation Branch report without duplicating the investigation unless there is credible evidence that the investigation as a whole was incomplete, flawed or deficient. The focus is on the investigation, not on whether individual conclusions are correct. If the threshold is met, the report cannot be selectively retained; a fresh investigation is required. A divisible investigation might justify a different approach, but that possibility did not arise on the facts.
3. Fairness did not require the Claimant to challenge the report afresh at the inquest. The Claimant had an opportunity to make representations under regulation 14 of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012. Coronial proceedings determine the cause of death and do not ordinarily determine civil or criminal liability. The public interest in avoiding duplication, expense and delay was therefore consistent with fairness.
4. The senior coroner applied the correct threshold. His references to whether the report or investigation was incomplete, flawed or deficient had to be read in context with his repeated statement of the correct test and his assessment of whether the Claimant’s material was capable of establishing credible evidence of such a defect.
5. The challenge based on the Workboat Code failed. Conclusion 3.1(6) addressed compliance with the Claimant’s own planning requirements and procedures, so the applicability of the Code was irrelevant to that conclusion. More generally, “in commercial use” in the Merchant Shipping (Small Workboats and Pilot Boats) Regulations 1998 extended, in context, to workboats used by a fire and rescue service. The Code therefore applied.
6. The remaining grounds were challenges to the assessment of evidence and the wording or emphasis of conclusions. They did not establish that the investigation was incomplete, flawed or deficient, nor that the ruling was irrational, inadequately reasoned or legally erroneous.