His Majesty’s Senior Coroner for West Yorkshire (Western District), Re

Under section 13 of the Coroners Act 1988, the High Court may order a fresh inquest where, in the interests of justice, this is necessary or desirable because relevant evidence was not considered at the original inquest. Fresh evidence need not be likely to produce a different conclusion. It is sufficient that it may reveal the substantial truth about the death, or that public examination of significant evidence is desirable. The interests of justice are assessed broadly. Desirability is a lower threshold than necessity and may be materially influenced by the deceased’s family seeking a further investigation. Where the new evidence may engage the procedural obligation under Article 2 ECHR, the court may also consider whether the original investigation adequately addressed the circumstances of the death.

The Senior Coroner for West Yorkshire applied under section 13(1)(b) of the Coroners Act 1988, with the Attorney General’s fiat, to quash the findings of an inquest into the death of Leonardo Pronesti and obtain an order for a fresh investigation and inquest.

The deceased had a history of mental ill-health and died by hanging. A package containing hundreds of pages of notes, letters and drawings indicating suicidal ideation had been left at a mental health unit before his death, but was not provided to the Assistant Coroner. After the inquest, the Assistant Coroner accepted that the documents would have been relevant and that he would probably have recorded a conclusion of suicide if he had considered them.

The central issue was whether the discovery of the documents and the resulting insufficiency of inquiry made a fresh investigation necessary or desirable in the interests of justice.

1. The application was granted. The determination and findings of the original investigation and inquest were quashed, and the claimant was ordered to conduct a fresh investigation and hold a fresh inquest under Part 1 of the Coroners and Justice Act 2009.

2. Section 13 of the Coroners Act 1988 requires a broad assessment of whether the interests of justice make a further investigation necessary or desirable. The emergence of fresh evidence which may reasonably show that the substantial truth about how a person died was not revealed will normally satisfy that test. A different conclusion need not be anticipated. Even evidence likely to confirm the original conclusion may make a fresh inquest desirable if public disclosure of the full evidence is appropriate. This approach followed Attorney General v HM Coroners for South Yorkshire (West) and West Yorkshire (West) [2012] EWHC 3783 (Admin).

3. Desirability is more readily established than necessity. The deceased’s family’s wish for a further investigation is a relevant consideration, as explained in In the Matter of the Inquest into the Death of Michael Vaughan [2020] EWHC 3670 (Admin).

4. The missing documents plainly concerned the deceased’s state of mind and intentions. Their absence meant that the Assistant Coroner had not considered evidence capable of materially affecting the conclusion. If a conclusion of suicide had been reached, section 5 of the Coroners and Justice Act 2009 might also have required consideration of whether the mental health trust and police had complied with an operational duty to protect life under Article 2 ECHR. The principles concerning when such an operational duty may arise were drawn from Rabone v Pennine Care NHS Foundation Trust [2012] 2 AC 72.

5. The documents also raised questions about whether the package should have been investigated further and whether the responses of the police and hospital required examination. A fresh investigation was therefore both necessary and desirable in the interests of justice.

6. The court expressed concern about the delay in the Attorney General granting the fiat, because it could increase the family’s anxiety and adversely affect the quality of evidence available for the fresh investigation. A copy of the judgment was directed to be sent to the Attorney General.