Sharon O'Brien v HM Assistant Coroner for Sefton, Knowsley and St Helens

A coroner has broad discretion to determine the scope of an inquest. The High Court should interfere only for a recognised public law error, including irrationality, material error of law, or a decision disabling the coroner from performing the statutory function.

Coronial causation requires proof, on the balance of probabilities, that the relevant conduct made an actual and material contribution to death, exceeding a minimal, negligible or trivial contribution. A mere increase in the chance of survival is insufficient. A causative chain dependent on speculation about what would have happened after a hypothetical arrest cannot satisfy that test.

The claimant sought judicial review of an Assistant Coroner’s decision concerning the death of Linda O’Brien. The Coroner concluded that Article 2 was not engaged, that there was no sufficient coronial causation between alleged police failures on 7 April 2020 and Linda’s death on 9 May 2020, and that the inquest should proceed without a jury and focus principally on events immediately before the death.

Permission was granted on the ground that the Coroner might have prematurely and irrationally found no causative connection, thereby unlawfully limiting the investigation’s scope. The central issues were whether the causative link could be established and whether the Coroner’s decisions on the jury and scope were unlawful.

1. The application for judicial review was dismissed. The Coroner was entitled to decide before the inquest whether a jury was required and to determine the scope of the investigation.
2. Under section 5 of the Coroners and Justice Act 2009, the coroner must investigate how the deceased came by death. Where Convention rights are engaged, section 5(2) requires an enhanced investigation. The coroner nevertheless sets the bounds of the inquiry.
3. The applicable coronial causation test required proof, on the balance of probabilities, that the relevant police conduct made an actual and material contribution to death exceeding a minimal, negligible or trivial contribution. It was insufficient that an arrest might have increased the chance that the deceased would have survived.
4. The suggested causal chain depended on speculation about whether an arrest would have occurred, whether a prosecution would have followed, whether bail or custody would have resulted, and whether the deceased would thereby have avoided the fatal events. Opinion evidence about the likely progress of a prosecution would have no reliable probative value. The Coroner was therefore entitled to conclude that causation could not be established.
5. The statutory threshold of “reason to suspect” for a jury under section 7(2) is low. However, the Coroner reasonably concluded that the death did not result from a police act or omission because the necessary causative link could not be established. The decision was neither premature nor irrational.
6. Although something apparently went wrong with the police databases on 7 April, a wide-ranging investigation into that matter would have been complex and inconsistent with the inquisitorial and relatively summary nature of an inquest, particularly where it could not affect the causation conclusion.

The judgment describes judicial review proceedings brought against the Assistant Coroner’s decision of 15 March 2023. HHJ Davies, sitting as a judge of the High Court, granted permission on one ground. The present court dismissed the claim.