Ellen Roome, R (on the application of) v The Senior Coroner for Gloucestershire & Anor

Under section 13(1)(b) of the Coroners Act 1988, the question is whether the interests of justice make a further inquest either necessary or desirable. A fresh inquest does not require proof that the original coroner was at fault or that a different conclusion will be reached. Significant new evidence may justify a fresh inquest even if it may confirm the earlier outcome. The court may assess the cumulative effect of investigative gaps and new evidence, giving weight to the family’s views. If the threshold is met, the High Court may quash the earlier inquest and order a fresh investigation and inquest.

The claimant, the mother of a 14-year-old who died after being found hanging, applied under section 13(1)(b) of the Coroners Act 1988 to quash the Record of Inquest and order a fresh investigation and inquest. She relied on insufficiency of inquiry and new evidence, including incomplete examination of electronic devices, possible social-media involvement, additional accounts, unexamined witnesses and other investigative leads. The Senior Coroner was neutral and TikTok did not oppose the application. The central issue was whether the interests of justice made a fresh inquest necessary or desirable.

Outcome. The Part 8 claim was allowed. The Record of Inquest, findings and conclusions of the 2022 inquest were quashed. A fresh investigation and inquest were directed. There was no order as to costs.

1. Statutory test. Section 13(1)(b) of the Coroners Act 1988 asks whether the interests of justice make another inquest necessary or desirable. The statutory alternatives are disjunctive, so desirability alone was sufficient. The court applied the approach in Her Majesty’s Attorney General v Her Majesty’s Coroner of South Yorkshire (West) & Her Majesty’s Coroner of West Yorkshire (West) [2012] EWHC 3783 (Admin) and Vaughan v HM Senior Coroner for Gwent [2020] EWHC 3670 (Admin). It therefore did not need to decide whether a fresh inquest was also necessary.
2. Fresh evidence and insufficiency of inquiry. A further inquest does not require a finding that the original coroner was at fault or an expectation that a different verdict will be returned. Relevant new facts or evidence may include material unavailable at the original inquest and relevant, admissible material that was not provided, as explained in R (Mays) v HM Senior Coroner for Kingston Upon Hull & East Riding of Yorkshire [2021] EWHC 3604 (Admin). The court assessed the cumulative effect of the material, although it recognised that the various matters did not all point in the same direction.
3. Material considerations. The court relied on the limited and non-forensic examination of electronic devices; the absence of social-media company data; two additional TikTok accounts; high TikTok use and removed content; the possible fraudulent Instagram contact and account lockout; witnesses who had not been questioned or questioned sufficiently; a possible location event; and the claimant’s account of the position in which she found her son. It also gave weight to the family’s reasonable wish for a fuller inquest. The court noted submissions concerning section 101 of the Online Safety Act 2023, but left any disclosure issue to the coroner.
4. Role of the court. The High Court’s role was confined to deciding whether the section 13(1)(b) threshold was met. The scope of the fresh investigation and inquest, and the evidence to be received, were matters for the coroner conducting it.