Elias Cherfan v His Majesty's Senior Coroner for West London

Under section 13 of the Coroners Act 1988, the interests of justice may require a fresh inquest where procedural irregularities have made the original investigation insufficient or unfair. A coroner considering an inquest in writing must comply with the statutory safeguards in section 9C of the Coroners and Justice Act 2009. The coroner must invite representations from known interested persons and must be satisfied that there is no real prospect of disagreement about the findings. If an inquest hearing is held, mandatory notice must be given to the next of kin under rule 9 of the Coroners (Inquests) Rules 2013. Breach of those requirements may justify quashing the record and ordering a fresh inquest, particularly where a different conclusion is reasonably possible and the family’s views were not considered.

The applicant, the father of Marc Antony Cherfan, challenged the record of an inquest into his son’s death. The inquest concluded that death resulted from suicide following a fatal pregabalin overdose.

The coroner had initially decided to conduct the inquest in writing without inviting the family’s representations. An inquest hearing was later held on documents because of an administrative IT failure, but the family was not notified of its date, time or place. The applicant applied under section 13 of the Coroners Act 1988 for the record and findings to be quashed and for a fresh investigation and inquest before a different coroner.

1. Application allowed. The Record of Inquest, findings and conclusions were quashed. A fresh investigation and inquest before a different coroner were ordered.
2. The decision to hold an inquest in writing was procedurally flawed. The family were interested persons whose representations had not been invited. Their correspondence indicated that they believed the death was an accidental overdose. In those circumstances, it could not reasonably have appeared that there was no real prospect of disagreement about the determinations or findings, contrary to section 9C(2)(a) and (c) of the Coroners and Justice Act 2009 and the relevant Chief Coroner’s Guidance.
3. The later documentary hearing compounded the irregularity. Rule 9(1) of the Coroners (Inquests) Rules 2013 required notice of the hearing to be given to the next of kin within one week of setting the date. The family’s earlier statement that they saw no point in an inquest did not permit the coroner to bypass that mandatory requirement.
4. Applying the principles in Sutovic v HM Coroner for Northern District of Greater London [2006] EWHC 1095 (Admin) and Attorney General v Coroner of South Yorkshire (West) [2012] EWHC 3783 (Admin), the court considered the possibility of a different verdict, the shortcomings in the original inquest and the interests of justice. A different conclusion was possible on evidence concerning the circumstances of the death. It was unnecessary for the court itself to determine the proper conclusion.
5. The court gave considerable weight to the family’s views, following The Inquest Into The Death Of Michael Richard Vaughan [2020] EWHC 3670 (Admin). The respondent’s neutral stance did not prevent an order for costs. Under the approach in R (Davies (No 2)) v HM Coroner for Birmingham [2004] EWCA Civ 207, [2004] 1 WLR 2739, the admitted breaches and the applicant’s need to fund the proceedings made it unjust for him to bear the whole financial burden. A contribution of £20,000 was ordered under section 13(2)(b) of the Coroners Act 1988.