HM Senior Coroner for South London v HM Assistant Coroner for South London
| Jurisdiction | England & Wales |
| Judge | Lord Justice Singh |
| Judgment Date | 12 May 2022 |
| Neutral Citation | [2022] EWHC 1388 (Admin) |
| Docket Number | No. CO/639/2022 |
| Court | Queen's Bench Division (Administrative Court) |
[2022] EWHC 1388 (Admin)
Lord Justice Singh
Mrs Justice Heather Williams DBE
No. CO/639/2022
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
ADMINISTRATIVE COURT
Royal Courts of Justice
Miss S. Milligan (instructed by Browne Jacobson LLP) appeared on behalf of the Applicant.
THE RESPONDENT did not appear and was not represented.
Introduction.
This is the judgment of the court to which both members have contributed.
This is an application for an order under section 13(2)(c) of the Coroners' Act 1988 (“the 1988 Act”) to quash the conclusion of an inquest held by the defendant Assistant Coroner on 10 August 2020 into the death of Mr Michael Leonard Baker. The application is made by Her Majesty's Senior Coroner for the South London area.
The defendant, who is an Assistant Coroner for the same area, consents to this application and the court has before it a consent order signed on behalf of both parties. As was fairly acknowledged by counsel, Miss Scarlett Milligan, who has appeared before this court today, the draft consent order, of course, does not bind this court. We shall return to it towards the end of this judgment.
The court also has before it an agreed statement of reasons in support of the consent order dated 22 April 2022. The defendant is functus officio and therefore has no power to withdraw or cancel her decision. This is why an order of this court is required and, quite properly, these proceedings have been brought in the interests of justice.
Factual Background.
Mr Baker was aged 59 at the time of his death on 23 April 2020. He had a significant medical history of asthma, being overweight and diabetes. The inquest recorded that those issues were under control. On the day before his death, 22 April 2020, Mr Baker was at home during the first national lockdown. He consumed some alcohol both before and with his dinner that evening. His wife, Mrs Kristina Baker, describes him as seeming “quite drunk” at around 9 p.m. When he went to bed he “smelt strongly of alcohol”. During the night Mr Baker went to the bathroom and fell asleep there. At around 4.50 a.m. on 23 April Mrs Baker woke up and went to the bathroom. She found Mr Baker kneeling on the floor in an awkward position, with his lips bleeding and swollen. She called for an ambulance. Paramedics arrived approximately five minutes later, but told her that her husband was already dead.
A post mortem was carried out on 29 April 2020 by Dr Anna Rycroft, a histopathologist. Her conclusions were subsequently amended in the light of a toxicology report. That toxicology report was prepared by Dr Susan Patterson on 18 May 2020. It recorded that the levels of alcohol found in Mr Baker's blood and urine were at a level where a “coma may occur” but were not at levels associated with death.
On 14 June 2020, Dr Rycroft's updated post mortem report made findings of a significant enlarged heart and a high blood alcohol level. The findings in the report included that while the alcohol level was below that which is associated directly with the fatality, the underlying natural disease had made Mr Baker more susceptible to the effects of alcohol.
On 10 August 2020 the defendant held an inquest into Mr Baker's death on the papers. We have seen a transcript of that inquest. The defendant stated in her determination:
“In my opinion the cause of death was:
(1) Hypertensive heart disease complicated by a huge alcohol toxicity …”
The record of inquest recorded the following conclusions at paragraph 2: “Medical cause of death: 1(a) Hypertensive heart disease complicated by acute alcohol toxicity.” At paragraph 3: “… the deceased died at home on 23 April 2020 having consumed alcohol to a level at which a coma can occur in the context of significant heart disease.” At paragraph 4: “Conclusion of the Coroner as to the death: Alcohol related”.
On 3 February 2022, the Attorney-General's Fiat to bring these proceedings was given by the Solicitor General. The claim form was issued on 2 March 2022.
Relevant Legislation.
Before turning to the current version of section 13 of the 1988 Act, we will refer to the version of that section which was in force from 10 July 1988 to 24 July 2013, because the contrast in wording with the current provisions is important. In the original version of section 13 the provisions of subsection (1) were as follows:
“(1) This section applies where, on an application by or under the authority of the Attorney-General, the High Court is satisfied as respects a coroner (‘the coroner concerned’) either—
(a) that he refuses or neglects to hold an inquest which ought to be held; or
(b) where an inquest has been held by him, that (whether by reason of fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, the discovery of new facts or evidence or otherwise) it is necessary or desirable in the interests of justice that another inquest should be held.”
Subsection 2 provided:
“(2) The High Court may …
(c) where an inquest has been held, quash the inquisition on that inquest.”
The original version of section 13 was amended by the Coroners and Justice Act 2009 (Consequential Provisions) Order ( SI 2013 no.1874) Article 2(5)(b) and (e). It is important, therefore, to set out the current terms of the material provisions which came into force on 25 July 2013. Section 13(1) now provides:
“(1) This section applies where, on an application by or under the authority of the Attorney-General, the High Court is satisfied as respects a coroner (‘the coroner concerned’) either …
(b) where an inquest or an investigation has been held by him, that (whether by reason of fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, the discovery of new facts or evidence or otherwise) it is necessary or desirable in the interests of justice that an investigation (or as the case may be, another investigation) should be held.”
Subsection (2) now provides:
“(2) The High Court may …
(c) where an inquest has been held, quash any inquisition on, or determination or finding made at that inquest.”
The Issues.
It is common ground that the principal issue for this court is:
“Was the defendant's conclusion irrational or unreasonable in the light of the failure to properly take into account material considerations, namely unchallenged medical evidence?”
Two consequential issues then arise: whether the court should quash the conclusion and, if so, whether the court can amend the conclusion and record of inquest for itself. It is common ground that the defendant's conclusion was irrational in the light of the uncontested medical evidence before the defendant. Her subsequent conclusion of “alcohol related” is inconsistent with her findings at the inquest. It would appear that she had intended to record both causes of death, as demonstrated by her oral findings and by consideration of the record of inquest when read as a whole. It is common ground before this court that it was Mr Baker's enlarged heart that caused his death but that this was likely to have been complicated, aggravated, or exacerbated by alcohol intake. The primary cause of death was, therefore, his enlarged heart and this should...
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