Ghaleb Makki, R (on the application of) v HM Senior Coroner for South Manchester

A coroner conducting a resumed inquest should strive to reach a conclusion on the balance of probabilities. If unable to do so, the coroner must explain why. A narrative conclusion cannot simply reproduce an open conclusion where the central factual issues remain unresolved.

An acquittal at a criminal trial does not prevent a coroner from considering unlawful killing, since the standards of proof differ. The coroner must analyse the relevant evidence, explain the significance of findings of fact, assess witness reliability, and address evidence bearing on self-defence and proportionality. A generic reference to considering the totality of the evidence is insufficient where the reasoning does not show that those matters were actually evaluated.

The claimant, whose son died from a stab wound, sought judicial review of a resumed inquest into the death. The Senior Coroner concluded that the precise circumstances could not be ascertained and returned a narrative conclusion.

The deceased’s companion, who accepted wielding the knife, had previously been acquitted of murder and manslaughter after relying on self-defence. The claimant contended that the coroner had failed to analyse the evidence relevant to who drew a knife first, the interested party’s credibility, the events preceding the stabbing, and the aftermath.

The central issues were whether the criminal acquittal prevented a conclusion of unlawful killing, and whether the coroner’s failure to explain her treatment of the evidence rendered the decision irrational.

1. Criminal acquittal and unlawful killing. Paragraph 8(5) of Schedule 1 to the Coroners and Justice Act 2009 prevented a resumed inquest determination from being inconsistent with the outcome of the criminal proceedings. It did not prevent consideration of unlawful killing. Under R (Maughan) [2021] AC 454, the question whether an unlawful killing occurred was determined on the balance of probabilities. A coronial finding of unlawful killing was therefore not inconsistent with a criminal acquittal.
2. Limits on coronial conclusions. Unless the coroner determined the issues of self-defence and accident, it would not be open, on the facts of this case, to conclude that the death was an unlawful killing. The self-defence inquiry required consideration of whether the defendant honestly believed force was necessary and whether the response was proportionate.
3. Requirement to strive for a conclusion. Since the inquest had been resumed after the criminal trial, it was in the public interest for the coroner to strive to reach a conclusion on the balance of probabilities, or explain why that could not be done. Open conclusions should be used only as a last resort. The narrative conclusion entered here was, in substance, an open conclusion.
4. Failure to analyse evidence. The coroner’s extensive narration of the evidence did not sufficiently distil it. She did not explain the relevance of her findings about the motorway-bridge incident, the relationship between the three youths, or the altercation concerning the coat. She did not assess the reliability of the knife-wielder’s evidence, explain the significance of his immediate false account, or weigh his evidence against the companion’s accepted evidence that a retracted knife was removed from the deceased’s inside jacket pocket.
5. The question who drew a knife first was not determinative of self-defence, but was plainly relevant to the belief in the need for force and the proportionality of the response. The generic reference to considering the totality of the evidence did not demonstrate that the coroner had striven to reach a conclusion. If she remained profoundly unsure, she had failed to explain why. The decision was therefore Wednesbury unreasonable.
6. The decision of 17 November 2021 was quashed. A fresh inquest before a different coroner was directed.

This was a first-instance judicial review claim. The challenged decision was the Senior Coroner’s narrative conclusion at the resumed inquest into the death.

• Criminal proceedings: The interested party was acquitted of murder and manslaughter after a trial in which he relied on self-defence.
• High Court (Administrative Court): The claim was allowed. The coroner’s decision was quashed and a fresh inquest before a different coroner was directed.