HM Senior Coroner for Cornwall and the Scilly Isles

Under section 13 of the Coroners Act 1988, the High Court may order a fresh inquest where newly discovered facts or evidence make that course necessary or desirable in the interests of justice. The applicant need not show that the fresh inquest will probably produce a different conclusion. Cogent new evidence may justify a fresh investigation where it reveals that the original inquest proceeded on an incomplete account of the circumstances of death, or where public examination of significant evidence is required, including evidence that may confirm the original conclusion. The interests of bereaved persons and the public interest are relevant considerations.

The Senior Coroner applied under section 13(1)(b) of the Coroners Act 1988 to quash two inquests and obtain fresh investigations. The inquests concerned the deaths of Edward John Masters and Mary Helen Rooker, both patients who died after elective surgery for abdominal aortic aneurysms at Royal Cornwall Hospital.

Following an invited service review and new expert evidence, concerns arose about consent, treatment, patient safety, and hospital systems. The central issue was whether the new facts and evidence made fresh investigations necessary or desirable in the interests of justice.

1. Both claims allowed. The determinations and findings of the original inquests were quashed. Fresh investigations and inquests were directed, which could in each case be conducted before the claimant. No order was made as to costs.

2. Section 13 of the Coroners Act 1988 requires the court to ask whether the interests of justice make a further inquest necessary or desirable. The court adopted the approach explained in HM Attorney General v HM Coroner of South Yorkshire (West) [2012] EWHC 3783 (Admin).

3. A fresh inquest does not depend on proof that a different verdict is probable. Significant fresh evidence may justify a fresh investigation even if it might confirm the earlier verdict, particularly where the substantial truth about the death was not revealed and the evidence should be publicly examined.

4. In both cases the original coroners had, through no fault of their own, acted on an incomplete picture. Cogent later evidence pointed to unacceptable standards of treatment and care by the surgeon and deficiencies in hospital processes. The interests of the bereaved and the public interest therefore required fresh investigations. Although probability of different findings was unnecessary, the court considered different findings likely on the evidence before it.

5. The statutory threshold was satisfied because the new facts and evidence made fresh investigations both necessary and desirable in the interests of justice.