Jada Bailey, R (on the application of) v HM Senior Coroner for East London

The claimant sought judicial review of the senior coroner’s decision not to resume the inquest into the death of her son. The court held that the coroner was entitled to conclude that the cumulative investigations — principally the criminal trial, the Serious Case Review and police complaint investigations — satisfied the investigative (procedural) obligation under Article 2 of the European Convention on Human Rights. The court applied the Jordan requirements (independence, effectiveness, promptness, public scrutiny and family involvement) in assessing whether those investigations collectively discharged the Article 2 duty. The coroner’s further assessment that any resumed inquest could not materially add to conclusions already reached, and that a Regulation 28 prevention report would not be a mandatory enforcement tool, was lawful. The claimant’s additional arguments about independence, public hearings, compulsion of witnesses and participation were rejected on the facts because the Serious Case Review was sufficiently thorough, investigative and offered meaningful opportunities for participation.

This judicial review concerned a decision of the Senior Coroner for East London not to resume an adjourned inquest into the death of a 14 year old boy (referred to in the Serious Case Review as "C") who was stabbed and killed on 8 January 2019. The inquest had been opened and then adjourned pending criminal proceedings. The accused was convicted and sentenced; the coroner subsequently issued a certificate that the inquest was not to be resumed. The claimant applied to the coroner in 2023 for resumption; the coroner refused on 18 March 2024 and this decision was judicially reviewed.

Nature of the application: judicial review of the coroner’s decision under paragraph 8(1) of Schedule 1 to the Coroners and Justice Act 2009; the claimant advanced three grounds but abandoned the pleaded common-law ground and focused on (1) alleged breach of the Article 2 investigative obligation, and (2) asserted legal error about the likely utility of a resumed inquest and failure to consider relevant matters.

Issues framed and decided:

• Whether the Article 2 investigative duty remained outstanding such that an inquest was required;
• Whether the Serious Case Review, criminal process and police complaint investigations collectively satisfied the Jordan requirements for an Article 2 investigation;
• Whether the coroner misdirected himself in concluding that a resumed inquest could add no material further conclusions or remedies beyond those investigations, including by failing to consider narrative conclusions or the utility of Regulation 28;
• Whether the coroner failed to take relevant matters into account (public interest in an inquest, statutory purposes of sections 5 and 10 of the 2009 Act, the possibility of a Regulation 28 report).

Reasoning and outcome: the court accepted that Article 2 investigative obligations were engaged but concluded that the Serious Case Review (SCR) by John Drew, together with the criminal trial and subsequent police complaint processes, amounted to an independent, effective, reasonably prompt and sufficiently publicly scrutinised investigatory process in this case. The SCR was found to be thorough, to have engaged with the claimant (including written answers and opportunity to comment on a draft), and to have identified factual findings and systemic and practice recommendations. The court found no legal error in the coroner’s analysis that any inquest conclusion would have to be consistent with the criminal verdict and therefore was unlikely to add material conclusions, and that a Regulation 28 report is a non‑prescriptive preventive report rather than an enforcement power. The coroner was held to have considered the relevant matters. The claimant’s application for judicial review was dismissed.

The claim is dismissed. The court concluded that Article 2 ECHR was engaged but that the cumulative investigations (criminal trial, Serious Case Review and police complaint processes) satisfied the Article 2 procedural investigative obligation under the Jordan criteria. The coroner did not err in law in concluding there was no sufficient reason to resume the inquest because a resumed inquest was unlikely to add materially to the conclusions already reached and a Regulation 28 report does not confer enforcement powers.