HM Assistant Coroner for Inner London Court, Re

Under section 13 of the Coroners Act 1988, the High Court may quash an inquest determination or finding and order a further investigation where fresh evidence means that the substantial truth about the death may not have been revealed and a different conclusion is reasonably likely. The interests of justice include ensuring that the inquest record accurately reflects the medical evidence and avoiding unnecessary stigma to the deceased’s memory. The Divisional Court cannot amend the findings in the record of inquest. Where amendment would be inadequate, the proper course is to quash the determination and order a fresh investigation and inquest under Part 1 of the Coroners and Justice Act 2009.

Karina Jane Brandt died in July 2020. Her inquest concluded that she had died from alcohol and drug toxicity in circumstances which were unexplained. A later review identified that the pathologist had transcribed the toxicologist’s stated usual endogenous GHB level incorrectly. The pathologist then issued a supplementary report concluding that there was no evidence that Ms Brandt had ingested GHB and revising the cause of death to unascertained.

With the authority of the Solicitor General, the assistant coroner applied under section 13 of the Coroners Act 1988 to quash the original determination and findings and obtain a fresh investigation and inquest. Ms Brandt’s parents supported the application. The parties agreed that the statutory and interests-of-justice requirements were met.

1. The determination and findings made at the inquest were quashed. A further investigation and inquest under Part 1 of the Coroners and Justice Act 2009 was ordered. There was no order as to costs.

2. The court was entirely satisfied that the fresh supplementary medical evidence constituted new evidence within section 13(1)(b) of the Coroners Act 1988. The correction materially changed the evidential position because the evidence no longer suggested that GHB had contributed to the death.

3. The new evidence could reasonably lead to the conclusion that the substantial truth about how the deceased died had not been revealed at the first inquest. A different conclusion at a fresh inquest was likely. It was therefore necessary or desirable in the interests of justice to quash the original determination and findings.

4. The interests of justice included the need for the inquest record to accurately reflect the medical evidence and the avoidance, so far as possible, of unnecessary stigma to the memory of the deceased. The court accepted the principle stated by Simon Brown J in R v Inner South London Coroner, ex parte Kendall [1988] 1 WLR 1186 at 1191–1192.

5. The court could not amend the findings recorded in the record of inquest. Following HM Senior Coroner for South London v HM Assistant Coroner for South London [2022] EWHC 1388 at paragraph 20, merely quashing the record and directing an amendment to state that the cause of death was unascertained would be inadequate. A full further investigation and inquest was required.