Emerald Josephine Toogood v HM Senior Coroner for the Area of Somerset

A coroner determining suicide must decide, on the balance of probabilities, whether the deceased intentionally performed the fatal act and intended thereby to kill themselves. The coroner need not exclude every speculative or remote alternative explanation, but suicide cannot be presumed and each element requires an evidential foundation. Reasonable inferences may be drawn from circumstantial evidence, including the mode of death. Judicial review is confined to public-law error. The court asks whether the conclusion was one reasonably open to the coroner, not whether another conclusion was possible. The coroner’s assessment of investigative scope, witnesses and expert evidence attracts substantial restraint.

The claimant sought judicial review of the Senior Coroner’s conclusion that her father, Joseph Toogood, had died by suicide after suffering a self-inflicted shotgun wound. She argued that accidental discharge could not be excluded, that psychiatric illness may have prevented him forming the necessary intent, that the expert evidence was inadequately explored, and that the coroner’s reasoning was irrational or speculative.

Permission was granted on limited grounds concerning the psychiatric expert evidence and the rationality of the findings on mechanism and intent. The central issues were whether the inquiry was procedurally flawed and whether the conclusion of suicide was reasonably open to the coroner.

1. The claim was dismissed. The inquest had been conducted lawfully, and the conclusion of suicide was within the range reasonably available to the coroner.
2. Under the common law, as confirmed in R (Maughan) v HM Senior Coroner for Oxfordshire [2020] UKSC 46, suicide requires proof that the deceased intentionally performed the act causing death and intended thereby to kill themselves. The applicable standard is the balance of probabilities.
3. The coroner was required to determine what probably occurred from the totality of the evidence. She was not required to eliminate every alternative hypothesis, particularly where it was speculative or remote. Suicide could not be presumed, but the necessary elements could be established by reasonable inferences from circumstantial evidence, including the mode of death. Lockley v Huntbach [1994] KB 606 and R v HM Coroner for the County of Devon, ex parte Glover (1985) 149 JP 208 illustrated the permissible use of inference.
4. The coroner had a broad discretion over the scope of the inquest, the witnesses called and the expert evidence required. The supervisory court could intervene only for a public-law failing, applying the principles in Associated Provincial Picture Houses Ltd v Wednesbury Corporation (1948) 1 KB 223 and CCSU v Minister for the Civil Service [1985] AC 374. The approach in Coroner for the Birmingham Inquests v Hambleton [2018] EWCA Civ 2801 was applicable.
5. The earlier approach in Lagos v Coroner for City of London [2013] EWHC 423 (Admin), requiring exclusion of all other explanations, was incompatible with the civil standard confirmed in Maughan.
6. The concepts of burdens and presumptions were generally inapposite in an inquisitorial inquest. The issue was whether the evidence supported the conclusion that the deceased intended to kill himself, not whether the claimant had discharged a burden under the Mental Capacity Act 2005.
7. The evidence of a close-range shotgun wound beneath the chin, the firearm’s working condition, the deceased’s familiarity with firearms, toxicology, psychiatric evidence and absence of clinical indicators of psychosis provided a sufficient basis for the coroner’s inference of intent. Further expert questioning was not shown to have been necessary for a fair inquiry.

First-instance judicial review claim. The High Court dismissed the claim.