Litvinenko, R (On the application of) v Secretary of State for the Home Department EWHC 194 (Admin)- read judgement
Neil Garnham QC and Neil Sheldon of 1 Crown Office Row represented the Secretary of State in these proceedings. They had nothing to do with the writing of this post.
This was an application by the widow of Alexander Litvinenko for judicial review of the refusal by the Secretary of State for the Home Department to order the setting up of a statutory inquiry into his death in London in November 2006. The Secretary of State had been asked to set up such an inquiry by Sir Robert Owen, the judge appointed to conduct the inquest into Mr Litvinenko’s death as Assistant Coroner.
Factual and Legal Background
Mr Litvinenko was taken ill on 1 November 2006 and died in University College Hospital on 23 November. There appears to be no doubt that the cause of death was radiation poisoning as a result of the ingestion of a radioactive substance, polonium 210. An “extremely thorough” investigation into the death was carried out by the Metropolitan Police Service with the assistance of the Atomic Weapons Establishment, Public Health England, the Health and Safety Executive, the Forensic Science Service and other external experts. Continue reading →
Brown v. HM Coroner for Norfolk  EWHC 187 (Admin) – read judgment
This is the sad tale of a young woman aged 31 dying in mysterious circumstances where the inquest went off entirely on the wrong footing. Joanne Foreman was not a diabetic but lived with a young boy who was. It was suspected that on the night before she died she had drunk heavily and then injected herself with insulin. The inquest proceeded on this basis. Nobody told the expert that the paramedics had taken a blood glucose from Joanne, which was entirely normal. Once this was known, it was obvious that the court would quash the findings at inquest and order a new inquest.
But the case contains powerful guidance from the Chief Coroner (sitting as a judge on this decision) about how to conduct the pre-inquest review.
As we watch the Covid-19 pandemic unfold our attention is naturally on the steps that HM Government (‘HMG’) is taking to mitigate the immediate crisis. The time is approaching, however, when it will be necessary to evaluate HMG’s preparation for, and response to, the pandemic. Calls are being made by the TUC and doctors’ groups for a public inquiry into one aspect of its response, namely failures to procure adequate personal protective equipment (‘PPE’) for NHS staff, at least 100 of whom are believed to have died having contracted the virus while treating patients. HMG is accused of failing to respond to a national exercise in 2016 testing the UK’s resilience to a similar flu pandemic which highlighted an increased need for ventilators. Other criticisms go further. This blog argues that the state owes a duty under Article 2 of the European Convention on Human Rights to investigate some deaths caused by Covid-19. This duty will require not only inquests into individual deaths but also a public inquiry under the Inquiries Act 2005 to address those systemic issues not suitable for determination by an inquest. The post builds on and responds to posts by Conall Mallory, James Rowbottom and Elizabeth Stubbins Banes. It also foreshadows the need for reform in this area.
2018 provided much food for thought for those practising in inquest law, with significant judgments on the burden on proof in suicide, on scope in relation to the Birmingham pub bombings, on causation in relation to medical negligence, on the relevance of non-causative findings to the record of inquest and on costs. In the most recent episode of Law Pod UK I am joined by Jeremy Hyam QC, who provides a whistlestop tour of this year’s the most significant cases.
Citations for cases mentioned on the podcast and links to related blog articles written by members of chambers are contained below, as is a brief analysis of R (Paul Worthington) v HM Senior Coroner for the County of Cumbria EWHC 3386 (Admin), a decision which was unfortunately handed down too late for consideration in the podcast episode. The episode is a available here.
The Foreign Secretary in February 2013 issued a certificate of Public Interest Immunity (PII), on the grounds of national security and/or international relations, to prevent the disclosure of a representative sample of Government documents relating to the 2006 poisoning. In May 2013 the Coroner for the Litvinenko Inquest (Sir Robert Owen) partially rejected that certificate and ordered the disclosure of gists of material relating to some of the key issues surrounding the death(read ruling). In this judgement, a panel of three judges of the High Court unanimously quashed that ruling.
The following post was written on the morning of 26 of March 2020. Today, 27th of March, the Chief Coroner brought out Guidance 35 on hearings during the pandemic (no. 35), with the proviso that all these issues will be kept under review.
On the 26th of March the Chief Coroner published Guidance Note 34 (“GN34”) on COVID-19 which can be found here. The Guidance Note addresses many of the issues relating to the impact of COVID-19 on the coronial service. We set out below some answers to questions those involved with the coronial system may currently have in mind, taken from the Guidance Note and other sources (“GN34#(No.)” refers to paragraph numbers in the Guidance Note).
1) Are Coroners’ Courts conducting hearings at the moment?
GN34#10 provides that “no physical hearing should take place unless it is urgent and essential business and that it is safe for those involved for the hearing to take place. A particular concern is to ensure social distancing in court and in the court building.”
It is also noted that
All hearings that can possibly take place remotely (via whatever means) should do so, and other hearings should continue only if suitable arrangements can be made to ensure distancing although the Chief Coroner accepts that in many jurisdictions this may be difficult. Hearings which must continue should be those considered essential business
Legal Services Commission v Humberstone, R.( On the application of)  EWCA Civ 1479 (21 December 2010) – Read judgment
The high court was right to quash the decision of the Legal Services Commission not to recommend public funding for a mother to be represented at the inquest into the death of her 10-year-old son. However, the court of appeal has ruled that the judge’s conclusions on when the state was obliged to conduct an expanded inquest into a death were confused.
The court of appeal has upheld the decision of Mr Justice Hickinbottom in the high court, although Lady Justice Smith came to her decision by a different route and criticised his reasoning. The case is important as it lays down guidelines for when legal representation for relatives of the dead should be funded at inquests, an often controversial issue, and how this fits with the state’s duties to investigate deaths under the European Convention on Human Rights. These duties have, partly as a result of Mr Justice Hickinbottom in this case, fallen into confusion, and the court of appeal has given a welcome clarification.
R (Lawal) v Secretary of State for the Home Department (2021), Upper Tribunal (Immigration and Asylum Chamber), Unreported, JR/626/2020 (V)— read judgment
The death of an immigration detainee, as with all prisoners, is rightly subject to legal scrutiny. This is because detainees are completely under the state’s control. Article 2 ECHR requires that the state carry out an effective investigation into all deaths in detention where there is a reasonable suspicion that the death was unnatural. A coroner is required to hold an inquest into all deaths in custody, and specifically a jury inquest where there is reason to suspect the death is violent or unnatural.
In this case, a two-judge panel of the Upper Tribunal (President of the Upper Tribunal, Mr Justice Lane, and Upper Tribunal Judge Canavan) found that the respondent Home Secretary had breached her Article 2 procedural obligations in respect of deaths in immigration detention. In particular, she had failed to ensure that crucial witness evidence was secured for use at an inquest and had failed to halt the deportation of a relevant witness.
Mr Oscar Lucky Okwurime (‘OO’) was a Nigerian national. On 12 September 2019 he was found dead in his room at Harmondsworth Immigration Removal Centre, aged 36. The applicant in these proceedings, Ahmed Lawal, was also a Nigerian national and a good friend of the deceased. He was detained on the same wing at the time of the death.
Re AB (Application for reporting restrictions: Inquest)  EWHC 1668 (QB) 27.6.19 (judgment here)
When seeking any order it always helps to make the right application, to the right court, following the right procedure. Although when it does go horribly wrong it at least provides valuable learning for the rest of us.
So make sure you are sitting comfortably, and get ready to be educated by Mr Justice Pepperall dishing out a lesson on making an application for reporting restrictions in respect of an inquest.
In Dove v HM Assistant Coroner to Teesside and Hartlepool & Anor  EWHC 2511, the High Court considered the State’s obligations under article 2 ECHR with respect to those in receipt of welfare benefits as well as the scope of coronial inquiries both where article 2 is and isn’t engaged. Although it was argued that failings by the Department of Work and Pensions were relevant to a death by suicide, a fresh inquest was refused in the circumstances.
The Applicant’s daughter, Ms Whiting suffered with spinal conditions and numerous mental health conditions. As a result, she was awarded employment support allowance [ESA] under the ‘support group’ category.
In September 2016, Ms Whiting began reassessment. By way of questionnaire she requested a home assessment, indicating she rarely left the house due to mobility issues and anxiety. This was not passed to the Centre for Health and Disability Services [CHDA] who decided that she was to attend a face-to-face appointment on 16th January 2017. On 6th February 2017, Ms Whiting was informed that her ESA would be stopped as she had not shown ‘good cause’ for her failure to attend and had not therefore demonstrated limited capacity for work.
On 21st February 2017 Ms Whiting, was tragically found unresponsive and was later pronounced dead. An inquest concluded she had died by suicide as a short-form conclusion. The Coroner told attendees that she had noted that there were ongoing discussions with the Department of Work and Pensions, but that it was not her function to question any decisions made by the Department.
However, a report by the Independent Case Examiner [ICE] in February 2019 (following a complaint made before the inquest had concluded) subsequently found that there had been “significant failings” by the Department in the events leading up to Ms Whiting’s death.
The Applicant applied to the Court under section 13 of the Coroners Act 1988 for an order quashing the Coroner’s determination and directing that a new inquest take place.
At an inquest, the Coroner must investigate four things: the identity of the deceased and how, when and where they came by their death. Ordinarily, the question ‘how the deceased came by their death’ means ‘by what means’ they came by their death (R v. North Humberside Coroner, ex parte Jamieson  QB 1).
Coroner for the Birmingham Inquests (1974) v. Hambleton & Ors.  EWCA Civ 2081 involved such an inquest. The central question for the Court of Appeal (composed of a panel including the Lord Chief Justice and the Vice-President of the Criminal Division of the Court) was whether, as part of his investigation into the deaths of the 21 victims of the 1974 Birmingham bombings, the Coroner was required to call evidence directed at identifying those responsible for the bombings. The Court of Appeal decided that, in this case, the Coroner was not so obliged.
R (Antoniou) v (1) Central and North West London NHS Foundation Trust; (2) Secretary of State for Health; (3) NHS England  EWHC 3055 (Admin) – read judgment
Where a patient, detained in hospital under Section 3 of the Mental Health Act 1983, takes their own life, Article 2 imposes procedural obligations on the State to investigate the circumstances of the death. These obligations are fulfilled by a coroner’s inquest. Unlike in prison and police station deaths, there need not be any independent investigation system prior to the inquest stage, and nor does Article 2 require one.
Applying for a fresh inquest is not straightforward. First, the bereaved have to get permission from the Attorney General. Only once that authority has been granted will they be allowed to apply to the High Court to reopen the inquest (section 13 of the Coroners Act 1988). Often cases are reopened because new evidence has come to light or there has been insufficiency of inquiry, for example where a person is found guilty of the murder of the deceased or new scientific data is provided. Further, it has to be necessary or desirable in the interests of justice that an investigation be (re)opened.
This case does not provide any new legal principles, but it is a strong statement about the importance of testing the evidence before granting the fiat: inquests should not be reopened just to allay the concerns of family members.
(1) Facts and Judgment
This case has a tragic backstory brought about by a complete breakdown of relations between a mother and her daughter-in-law.
Ray Farrell died on 24 October 2016 aged 53 as a result of malignant mesothelioma, which he developed following asbestos exposure working as a mate’s fitter. He had settled a civil claim with his former employer prior to his death. The documentary-only inquest recorded the cause of death as mesothelioma. There was no post mortem or toxicology, as the histology of mesothelioma was considered sufficient.
Concerns were first raised by his daughter, Kelly, who had not been informed of her father’s illness and therefore was shocked to discover his illness and death. Her suspicions were raised by two matters: two carrier bags full of medicines awaiting disposal following his death and a response from the Senior Coroner to her email that there were no toxicology or blood samples because Mr Farrell’s wife, and her stepmother, was very anxious to avoid a post mortem. In fact, it was Mr Farrell who did not want a post mortem.
Her concerns were then taken up by Ray’s mother, Mrs Farrell. She applied for a fresh inquest on the basis that Mr Farrell’s wife, Amanda Burden, hastened his death by deliberately giving him inappropriate medication. Ms Burden and Mr Farrell had been married in February 2016, although they had been in a relationship for eight years. She was, Mrs Farrell alleged, motivated by financial gain. Mrs Farrell applied with the fiat of the Attorney General under s.13 of the Coroners Act 1988 for the quashing of the original inquest due to a lack of appropriate investigation. The Senior Coroner supported the fiat, although doubted whether the outcome would be any different.
R (Peter Skelton and anr) v Senior Coroner for West Sussex  EWHC 2813 (Admin) — Judgment here.
Susan Nicholson and Caroline Devlin were killed by the same man during the course of abusive relationships. They died in 2011 and 2006, but the man was not convicted – of murder and manslaughter respectively – until 2017. The inquest into Susan’s death in 2011 resulted in a verdict of accidental death. Following the murder conviction, the Coroner applied to the High Court for this to be quashed, with the intention of holding a short inquest at which a fresh conclusion of “unlawful killing” would be recorded. However, the Claimants in this case – Susan’s parents – sought to expand the scope of the inquest to consider what they thought, understandably, were police failings. They were successful; this blog explains why, and examines the wider implications of the ruling.
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