Douglas and Carol Shipsey v HM Senior Coroner for Worcestershire

On an application for a fresh coronial investigation, the question is whether the interests of justice make another investigation necessary or desirable. Fresh evidence which may reasonably show that the substantial truth about the death was not revealed at the original inquest will ordinarily satisfy that test. The family’s views are a material consideration, particularly after substantial delay.

Under section 13(2)(c) of the Coroners Act 1988, the court may quash part of a determination or finding without substituting its own conclusion. It may also decide that no fresh investigation is required where the remaining record answers the statutory questions and is neither misleading nor incomplete.

Bethany Shipsey died after ingesting Dinitrophenol tablets. Her parents challenged the narrative conclusion at the 2018 inquest, which stated that she had died by suicide and had intended to take her own life.

The original judicial review proceedings were refused permission. The parents later obtained the Attorney General’s fiat and brought this application under section 13 of the Coroners Act 1988, relying on fresh family, psychiatric and toxicological evidence concerning Bethany’s intention. They also advanced a separate insufficiency-of-inquiry ground and, shortly before the hearing, sought to introduce further arguments concerning unlawful killing. The court determined the application on the original fresh-evidence ground. The central issues were whether the section 13 test was met and what relief was available.

1. Application granted. The combined effect of the fresh evidence reasonably led to the conclusion that the substantial truth about how Bethany died had not been revealed at the original inquest. A different conclusion on intention was possible. The section 13(1)(b) test was therefore satisfied: a further investigation was both necessary and desirable in the interests of justice, applying HM Attorney General v HM Coroner of South Yorkshire (West) and another [2012] EWHC 3783 (Admin).
2. The fresh material comprised further family evidence and social-media messages, independent psychiatric evidence supporting an interpretation of the ingestion as impulsive self-harm rather than suicidal intent, and toxicological evidence suggesting that Bethany had taken substantially fewer tablets than the original coroner had accepted. The evidence had to be assessed cumulatively. The fact that some material might have been obtainable before the original inquest was not decisive. The family’s views were material and deserved considerable weight, particularly given the delay: HM Senior Coroner for Gwent re the Inquest into the Death of Vaughan [2020] EWHC 3670 (Admin); Bloom v North London Assistant Deputy Coroner [2004] EWHC 3071 (Admin).
3. There had been no insufficiency of inquiry. The original investigation and inquest had been comprehensive and sensitive. The application succeeded on Ground 1, so Ground 2 did not require determination.
4. Section 13(2)(c) permits the court to quash part of a determination or finding, removing or red-lining offending wording, although it does not permit substitution of the court’s own conclusion. The amended statutory language, introduced by the Coroners and Justice Act 2009 (Consequential Provisions) Order 2013, gave the court greater flexibility. Earlier observations to the contrary concerned substitution or were obiter, including HM Senior Coroner for South London v HM Assistant Coroner for South London [2022] EWHC 1388 (Admin) and Re HM Senior Coroner for Northamptonshire [2024] EWHC 2331 (Admin).
5. A fresh investigation need not accompany every successful section 13(2)(c) application. The powers in section 13(2) are disjunctive. Here, removing the suicide and suicidal-intent wording left a complete narrative answering the statutory questions, so no fresh investigation was necessary. No order for costs was made.

• High Court (Administrative Court): Permission for the earlier judicial review challenge was refused on 24 April 2021 by David Lock QC, sitting as a Deputy Judge. The present Divisional Court later granted the section 13 application on the fresh-evidence ground and quashed specified parts of the Record of Inquest.
• Supreme Court: The earlier judicial review proceedings had been stayed pending R (Maughan) v Oxfordshire Senior Coroner, which changed the applicable standard of proof for a suicide conclusion: [2020] UKSC 46; [2021] AC 454.