Natasha Miranda Bryan, R (on the application of) v His Majesty’s Assistant Coroner for Buckinghamshire

Inquests are inquisitorial fact-finding proceedings, not criminal trials. Criminal presumptions and burdens of proof relating to insanity should not be transplanted into the coronial context. The coroner must decide, on the evidence as a whole, whether insanity is sufficiently raised for consideration. If it is, the issue is whether, on the balance of probabilities, the deceased was not legally insane when the fatal act occurred. Deliberate or apparently controlled conduct does not, by itself, establish that the person was sane or acting rationally. A coroner’s conclusion must be read fairly and straightforwardly, without excessive legalism. Where the coroner’s conclusion is reasonably open on the evidence, a rationality challenge will fail.

The claimant, the paternal aunt of a child killed at Taplow Station with her mother, challenged the Assistant Coroner’s narrative conclusion concerning the child’s death. The Coroner concluded that the mother had intentionally entered the path of a train while holding the child, but that it was not possible to determine that she was not legally insane at the time.

The claimant alleged that the Coroner had wrongly reversed the presumption of sanity and had irrationally declined to conclude that the child was unlawfully killed. The Divisional Court considered the proper approach to insanity in an Article 2 inquest and whether the Coroner’s reasoning and conclusion were legally rational.

1. The claim was dismissed. The Coroner’s narrative conclusion was upheld.
2. An inquest is an inquisitorial fact-finding inquiry. It has no defendant, prosecution or defence, and no person bears a criminal burden of proof. The fairness considerations identified in R v HM Coroner for North Humberside and Scunthorpe, Ex p Jamieson therefore remain applicable notwithstanding the civil standard of proof for short-form conclusions established in R (Maughan) v Coroner for Oxfordshire.
3. The criminal presumption of sanity under the M’Naghten rules should not be applied in coronial proceedings. The issue is whether insanity is properly raised on the evidence. If it is, the coroner must determine, on all the relevant evidence and on the balance of probabilities, whether the person was not legally insane at the time of the act. If insanity was more likely than not, a conclusion of unlawful killing would be unsafe.
4. The coroner has a broad discretion concerning the evidence to call, the procedure, the scope of the inquiry and the issues to be considered. That discretion must nevertheless be exercised rationally and consistently with the Tameside duty. Psychiatric evidence is likely to be significant, but direct or circumstantial evidence of behaviour before, during or after the act may also be relevant.
5. The Coroner had not adopted a presumption of insanity. Reading his conclusion fairly and without excessive legalism, the reference to the second sentence of paragraph 32 of the Chief Coroner’s Law Sheet No 1 implicitly reflected the preliminary question whether insanity had been raised. The Coroner’s double negative was inelegant, but its meaning was sufficiently clear.
6. The evidence rationally permitted the Coroner to conclude that insanity was properly raised and that he was not satisfied that the mother was not insane, or that she was likely to have been insane, when the fatal act occurred. Deliberate, controlled or apparently purposeful conduct did not determine the issue, because psychosis may coexist with deliberate action. The evidence had to be assessed as a whole, including the history of episodic psychosis, irrational behaviour and the absence of direct evidence of the mother’s state of mind at the time.