William Leeson, R (on the application of) v His Majesty’s Area Coroner for Manchester South

A coroner must determine the scope of an inquest rationally and in accordance with the statutory purpose of discovering how the deceased came by their death. The inquiry is not confined to the final physical events causing death. Evidence occurring before or after those events may be relevant, including evidence capable of making unlawful killing more likely than accident. The prohibition on framing a determination as criminal liability does not require exclusion of evidence relevant to the statutory question. A coroner retains control over the evidence and may adopt proportionate means, including written evidence, but cannot exclude material evidence for an improper reason.

The claimant, the father of Paula Leeson, sought judicial review of the Area Coroner’s ruling restricting the temporal scope of her inquest to her arrival in Denmark on 3 June 2017 until her death by drowning on 6 June. Medical evidence was consistent with either accidental drowning or unlawful killing. Her husband had been acquitted of murder after a submission of no case to answer, but the criminal proceedings had involved evidence concerning substantial life-insurance policies and other circumstantial matters before and after the death.

The claimant argued that excluding that evidence frustrated the statutory purpose of the inquest. The central issue was whether the Coroner had lawfully and rationally limited the evidence relevant to determining how Ms Leeson came by her death.

1. Claim allowed and ruling quashed. The Coroner’s ruling of 18 August 2021 restricting the temporal scope of the inquest was unlawful. The matter was remitted to the Coroner for reconsideration in accordance with the judgments of the Court.
2. An inquest is an inquisitorial statutory process directed to discovering the truth about how, when and where a deceased came by their death. It is not a trial of criminal or civil responsibility. The Coroner has discretion over the evidence, but that discretion must be exercised rationally.
3. The statutory question of how the deceased came by her death is not confined to the last link in the chain of causation. Evidence of motive and other circumstantial matters may be relevant to whether the appropriate conclusion is unlawful killing or accident. The insurance evidence and other matters excluded by the ruling could make unlawful killing more likely, particularly where the medical evidence might not itself resolve the issue.
4. The restriction was impermissibly narrow. Although the ruling did not prevent either possible conclusion, it excluded relevant evidence about whether unlawful killing was more likely than accidental death without proper reason. Section 10(2) of the Coroners and Justice Act 2009 prevents a determination appearing to determine the criminal liability of a named person, but does not require exclusion of evidence relevant to the statutory inquiry.
5. The Coroner must decide how the evidence is to be adduced proportionately on remittal. Rule 23 of the Coroners (Inquests) Rules 2013 may permit written evidence, particularly where the underlying insurance facts are largely undisputed and the relevant issue concerns their evidential significance.

The judgment does not state a prior appellate decision in this litigation. The claim was a first-instance judicial review of the Coroner’s ruling dated 18 August 2021.