Elizabeth Olabode, R (on the application of v His Majesty's Area Coroner For Manchester City

An inquest must focus on determining who the deceased was and how, when and where the death occurred. A coroner may limit findings to the central, potentially causative issues, provided the evidence is assessed rationally and the reasons explain how the principal controversies were resolved.

In a judicial review of an inquest, the court must not conduct an appeal on the facts or substitute its own assessment of competing expert evidence. Where expert evidence is complex and conflicting, it should be assessed in the round. A failure to analyse a potentially material issue may constitute a public law error, but relief depends on materiality. A failure in care must have contributed to death more than minimally, negligibly or trivially before it can require a causative narrative conclusion.

The claimant sought judicial review of the findings of fact and short-form natural-causes conclusion reached by the area coroner following the inquest into the death of her 12-year-old daughter, who had sickle cell disease. The coroner found failures in care, including delayed imaging, but concluded that they had not more than minimally contributed to the death.

The claimant alleged that the coroner had failed to consider clinical evidence concerning posterior reversible encephalopathy syndrome and an alternative treatment plan, had irrationally discounted causation evidence, and had misdirected himself on material contribution. Permission had initially been refused, including in [2024] EWHC 3471 (Admin), but was later granted. The central issue was whether the coroner’s reasoning disclosed a material public law error.

1. Claim dismissed. The coroner was entitled to return a short-form conclusion of natural causes despite identifying failures in care, because he found insufficient evidence that those failures had contributed to death more than minimally.
2. An inquest is a fact-finding inquiry governed by the statutory purpose in section 5 of the Coroners and Justice Act 2009. The coroner was required to focus on the central potentially causative issues and was not required to refer to every part of the evidence.
3. The judicial review court could not re-hear the evidence or substitute its own view. The question was whether the coroner reached a conclusion open to a reasonable coroner. The extensive expert evidence had to be assessed in the round, with conflicts resolved where necessary.
4. The coroner had expressly found that imaging should have been undertaken earlier and that a neurological event should have been investigated. He nevertheless considered the proposed alternative treatment path, including the evidence concerning suspected PRES, imaging, fluid and blood-pressure management, exchange transfusion and ketamine.
5. The coroner was entitled to reject the contention that earlier imaging would probably have revealed subarachnoid blood. The expert evidence did not establish that suspected PRES was in fact present, that the proposed treatment would have prevented the later catastrophic event, or that the relationship between PRES and the cerebral ischaemia was sufficiently clear.
6. Ground 2 failed because the coroner’s discussion of Professor Kirkham’s evidence concerned the specific hypothetical issue of whether delayed scanning had contributed to death. It was not a wholesale rejection of her evidence. Any possible error would in any event have been immaterial.
7. The alleged misdirection based on the phrase whether death would have been avoided was unfounded. The coroner had directed himself to the correct more-than-minimal causation test. Had Ground 1 succeeded, the error would have been material, but Ground 1 failed.

The claim was a first-instance judicial review. Permission was refused by judges of the High Court on 16 September 2024 and 12 November 2024, the latter decision being reported at [2024] EWHC 3471 (Admin). Permission was subsequently granted by Holgate LJ on 24 June 2025. The Administrative Court dismissed the substantive claim.