Shaun Morrow v HM Assistant Coroner for Merseyside (Sefton, Knowsley and St Helen's)

Under section 13 of the Coroners Act 1988, a fresh inquest is required only where an identified defect has diverted justice or made the inquiry insufficient, and ordering one is necessary or desirable in the interests of justice.

A coroner has a wide discretion to define the scope of an inquest, subject to the prohibition on determining civil or criminal liability. The coroner may confine the inquiry to the immediate circumstances and physical cause of death. Administrative shortcomings, limits on questioning, and the reading of witness statements will not justify a fresh inquest where the inquiry remained lawful and sufficient and the conclusion was rationally open on the evidence.

The claimant, acting under the Attorney-General’s fiat, sought a fresh inquest into the death of his sister, Zoe Morrow. The original inquest concluded that she had died from mixed drug toxicity and rejected a conclusion of suicide because the coroner was not satisfied that she intended to kill herself.

The claimant alleged that the coroner had failed to investigate treatment shortcomings, excluded relevant family evidence, mishandled witness evidence, acted unfairly, and colluded with the NHS trust. The central issues were whether the inquest was unlawfully confined and whether the evidence required a fresh consideration of suicide.

1. The application under section 13 of the Coroners Act 1988 was refused. The court found no substantial defect, no diversion of justice, and no insufficiency of inquiry requiring a fresh inquest.
2. Where process problems are relied upon, a fresh inquest is required only where those problems meant that justice was diverted or the inquiry was insufficient: HM Attorney General v HM Coroner of South Yorkshire (West) [2012] EWHC 3783 (Admin) at paragraph 10.
3. The coroner was entitled to confine the inquest to the immediate circumstances of Zoe’s death and its physical cause. The scope did not extend to determining whether the trust’s treatment failures caused or contributed to the death, since section 10(2) of the Coroners and Justice Act 2009 prohibits determination of civil or criminal liability. Evidence concerning earlier treatment could therefore be treated as background, and the coroner was entitled not to call treating clinicians in person.
4. A conclusion of suicide required both a deliberate act and an intention that death would result. The coroner had evidence of previous attempts, mental-health concerns, and the quantity of drugs and alcohol consumed, but also evidence pointing away from an intention to die. It was rational and lawful to conclude that the death was drug-related without reaching a suicide conclusion.
5. The coroner was entitled to control questioning, read relevant witness statements under rule 23 of the Coroner’s (Inquests) Rules 2013, and proceed despite the late service of one witness statement. Those were lawful case-management decisions. Although clearer explanation of the limited scope and process would have been helpful, the identified administrative oversights did not make the inquest unfair or unlawful.

• Original inquest: An inquest conducted on 31 March 2022 concluded that Zoe Morrow died from mixed drug toxicity and rejected suicide.
• High Court (Administrative Court): The application for a fresh inquest was refused.