In this case the claimant successfully challenged a Senior Coroner’s decision not to resume an adjourned inquest into the death of his mother, Ms Baker.
The claimant’s sister had been admitted to hospital under section 2 of the Mental Health Act 1983 and later remained in hospital as a voluntary patient on an open ward. She absconded from hospital and staff raised concerns with the police that she was “unwell and psychotic” and further raised concerns as to the welfare of Ms Baker, the claimant’s mother. Several days later, police found Ms Baker deceased in her home and the claimant’s sister was arrested. An inquest was opened and adjourned pending the conclusion of the criminal proceedings.
There was no criminal trial due to an acceptable plea having been entered by the claimant’s sister.
An internal ‘route cause analysis’ investigation report was undertaken by Oxford Health NHS Foundation Trust and a Domestic Homicide Review was undertaken by Oxford Safer Communities Partnership.
The Senior Coroner decided not to resume the inquest and upheld this decision after being invited to reconsider it by the claimant. The test applied by the coroner when deciding whether the inquest ought to be resumed in accordance with paragraph 8 of Schedule 1 of the Coroners and Justice Act 2009 was: “..whether the facts of the death [had] been adequately aired in public”. He concluded that the issues to be determined had been adequately aired at the Crown Court trial and that the aforementioned investigations (in combination with the Crown Court trial) were sufficient to satisfy Article 2 European Convention on Human Rights.
It was submitted on behalf of the claimant that:
(1) the Senior Coroner applied the wrong test when deciding whether or not to resume the inquest; and
(2) that the investigations he relied on to make his determination were not capable of discharging the investigative duty under Article 2 of the ECHR and/or the common law obligations to do so.
It was decided that the Senior Coroner had applied the wrong test for the resumption of the inquest. The test required the coroner to consider “whether there is sufficient reason for resuming the inquest”. The investigative duty under Article 2 was noted to be “clearly triggered”. There had been no Crown Court trial (an acceptable plea had been entered) and the investigations were not public: the NHS Trust’s investigation was internal and the Domestic Homicide Review was marked ‘private and confidential’. The Senior Coroner’s decision not to resume the inquest was therefore unlawful and in breach of both the investigative duty under Article 2 ECHR and the common law.
The Chief Coroner noted that 16(3) of the Coroners and Justice Act 2009 “expressly envisages, rather than discourages” the resumption of an inquest after a criminal conviction.
So, in short, this decision has offered further clarity about how coroners should approach the task of resuming an inquest after a criminal conviction to ensure that deaths are fully investigated.
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