Article 2 inquests: new judicial guidance on what should be included in a Coroner’s conclusion

The High Court, together with the Chief Coroner have recently considered a judicial review of a Coroner’s decision in Wales relating to a conclusion reached in an Article 2 inquest: R (Carole Smith) v HM Assistant Coroner for North West Wales.

The brief facts of the case are that a 27-year-old patient hanged herself at home after receiving care from a mental health provider for approximately a month before her death. The Welsh Health Board’s own investigation recorded failings relating to the care that she received, as did an expert forensic psychiatrist instructed by the Coroner. However, there was a difference in opinion relating to causation. The Health Board considered that the outcome would not have been different for the deceased had the care been different and the expert considered that her death was entirely preventable.

After hearing the evidence, the Coroner recorded no critical or judgmental findings in Box 3 or Box 4 and no neglect rider which had been argued for by counsel for the family.  

As a result of the conclusion, the family applied for a judicial review of the decision on the basis that the decision was irrational and flawed.

There were four key arguments:

1. The Coroner had erred in law on the threshold and standard of proof for causation in death.
2. It was irrational for the Coroner to fail to accept the expert evidence.
3. The Record of Inquest was not Article 2 compliant.
4. It was irrational to fail to find neglect.

All the grounds for the judicial review were rejected.

A brief summary of the judicial reasoning is as follows:

• Statistics do not prove causation. In this case, the expert’s evidence relied heavily on the deceased being part of a statistical likelihood, but what was required was evidence that she would have fallen within that statistical group that on the balance of probability she would have survived.
• Coroners do not have to accept their own or any expert evidence. The Coroner in this case had carefully examined the evidence and questioned the expert and their opinion and preferred the clinicians’ evidence.
• An Article 2 compliant inquest does not have to record failings in the conclusion. A Coroner’s reasons given in open court also form part of the public record. Brevity and simplicity of a conclusion must not be lost. However, a note of caution, this case related to an Article 2 inquest where a Coroner sat alone. In jury inquests, it is likely to be continued to be argued by those representing the deceased and their families that the judgment in Tainton should be followed, which states that admitted failings should be in the recorded conclusion.

Submissions based on this case are likely to be heard by Coroners from parties representing public bodies and families in the future. It is an interesting case that is worth a read and one where we may see (and would welcome) further guidance from the Chief Coroner in the future.

Stuart Knowles and Katrina McCrory