HM Senior Coroner for Sefton Knowsley and St Helens v Michael Kay & Ors

Under s.13 of the Coroner’s Act 1988, a fresh inquest may be ordered where it is necessary or desirable in the interests of justice. Fresh evidence need not make a different verdict probable, or even create a possibility of one, although that possibility is a powerful factor. The court must consider all relevant circumstances, including shortcomings in the original inquest, the nature of the new evidence, the family’s wishes, the passage of time and any delay in applying. The court should not itself determine the factual issues reserved for the coroner. Where undisclosed evidence may affect the deceased’s state of mind or the recorded conclusion, quashing the original inquest and ordering a fresh inquest may be justified.

The Senior Coroner applied, with the Attorney General’s permission, to quash an inquest into Michelle Kay’s death and order a fresh inquest. The original inquest recorded bronchopneumonia and mixed-drug toxicity and stated that there was no indication of suicide.

After the inquest, medical records, handwritten notes and evidence of earlier overdoses came to light. The deceased’s parents opposed reopening the matter, while the NHS Trust remained neutral. The central issue was whether, having regard to the new evidence and all the circumstances, a fresh inquest was necessary or desirable in the interests of justice.

1. Disposition. The court quashed the determination and findings made at the inquest on 3 February 2021 and ordered a fresh inquest before a different coroner in the same area.
2. Statutory approach. Section 13 of the Coroner’s Act 1988 requires the court to ask whether a further investigation is necessary or desirable in the interests of justice. The statutory grounds are broad. The court adopted the approach in Sutovic and Attorney General v Coroner of South Yorkshire (West), including consideration of the possibility of a different verdict, shortcomings in the original inquest and the significance of new evidence.
3. A possibility of a different conclusion is not a pre-condition. A fresh inquest may also be desirable where significant new evidence might confirm the earlier conclusion but should be publicly examined. The wishes of the deceased’s family, the time elapsed and delay in bringing the application are relevant factors, but none is determinative.
4. Here, the undisclosed medical records and handwritten notes might bear on Michelle’s state of mind and on the conclusion that there was no indication of suicide. They therefore created a possibility that the coroner might reach a different conclusion or express it differently. The court expressly left those factual questions to the coroner.
5. The family’s opposition, the passage of more than three and a half years since the death, and unexplained delay by the coroner were taken into account. On the whole circumstances, however, a fresh inquest was necessary in the interests of justice.

Not an appeal. The judgment concerns an application under s.13 of the Coroner’s Act 1988 with the permission of the Attorney General.