R Evandro Lagos v HM Coroner for the City of London Anele Austin (Interested Party)
| Jurisdiction | England & Wales |
| Judge | Mrs Justice Lang DBE |
| Judgment Date | 14 March 2013 |
| Neutral Citation | [2013] EWHC 423 (Admin) |
| Docket Number | CO/12447/2011,Case No: 12447/2011 |
| Court | Queen's Bench Division (Administrative Court) |
| Date | 14 March 2013 |
and
[2013] EWHC 423 (Admin)
The Honourable Mrs Justice Lang DBE
Case No: 12447/2011
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
ADMINISTRATIVE COURT
Royal Courts of Justice
Strand, London, WC2A 2LL
The Claimant appeared in person Jonathan Hough (instructed by Withers LLP) for the Defendant
Hearing dates: 27 th February 2013
The Claimant applies for judicial review of the verdict at an inquest conducted by the Defendant on 20 th September 2011 into the death of his wife, Nuelia Nunes Lagos.
On 28 th July 2010, Nuelia Lagos was found dead at Breton House, Barbican, London EC2Y 8DQ. Her date of birth was 6 th June 1977 and so she was 34 years old. At the inquest, the Defendant, who sat without a jury, recorded an open verdict.
In summary, the issues in the judicial review are:
a) whether the Defendant should have returned a verdict of suicide;
b) whether the procedure adopted at the inquest was unfair, in particular arising from:
i) the change of interpreter;
ii) the witness evidence.
Disclosure of the police report
On numerous occasions, the Claimant has applied unsuccessfully to the court for disclosure of the police report sent to the Defendant. He renewed his application at the commencement of the hearing, and I refused it.
The police report is a document prepared specifically for the Coroner, which summarises the police investigation, the identity and evidence of any witnesses, and the provisional conclusions of the investigating officer. It is intended to assist the Coroner in understanding the issues and deciding which witnesses are to be called. Police reports are not adduced in evidence at inquests because they are not primary evidence.
In accordance with usual practice, the police report was not adduced in evidence in this case. The Defendant objected to disclosure on the ground that it was a confidential document which could not be relevant to the judicial review claim since it was not part of the evidence upon which he reached his verdict.
Generally, the evidence in a judicial review claim is limited to the material which was before the decision-maker when he made his decision. Other material is usually irrelevant and therefore not liable to be disclosed. Exceptionally a Claimant might obtain disclosure of material which was not before the decision-maker, if he could establish that it might be relevant to the grounds of review.
In this case, I did not consider that the police report was relevant to the Claimant's grounds of review.
Detective Constable Briars gave oral evidence at the inquest describing the nature and outcome of the police investigation. Mrs Lagos' body was found at the bottom of a deep well, below a walkway with a barrier. The evidence indicated that she impelled herself from the bar at the top of the barrier and fell backwards, resulting in her death. DC Briars said that there was no evidence of any other person being involved in her death, and no sign of any attack upon her. Taking into account her history of depression and anxiety, suicide was the most probable explanation. However, since no one saw the fall, an accident could not be ruled out, for example, if she sat on the bar and slipped backwards, or was gently pushed by a passerby, which he acknowledged was highly unlikely.
DC Briars's conclusion that the probable explanation was suicide is consistent with the Claimant's own analysis, and therefore the Claimant would have no reason to challenge it. It is fanciful to imagine that DC Briars withheld any information in the police report which would have shed any further light on the cause of death. The Claimant said he was searching for scientific evidence of suicide; however, there is nothing to suggest that such evidence existed.
For these reasons I concluded that the police report was not relevant to the claim for judicial review. I did however order disclosure of the police photographs and the evidence relating to the fingerprints as this material was in evidence at the inquest.
The legal framework
Inquests are governed by the Coroners Act 1988 ("the Act") and the Coroners Rules 1984 ("the Rules"). Section 11 of the Act concerns the proceedings at an inquest and provides as follows:
"(2) The coroner shall, at the first sitting of the inquest, examine on oath concerning the death all persons who tender evidence as to the facts of the death and all persons having knowledge of those facts whom he considers it expedient to examine.
…
(4) In the case of an inquest held without a jury, the coroner shall, after hearing the evidence –
(a) give his verdict and certify it by an inquisition; and
(b) inquire of and find the particulars for the time being required by the 1953 Act to be registered concerning the death.
(5) An inquisition –
(a) shall be in writing under the hand of the coroner…
(b) shall set out, so far as such particulars have been proved –
(i) who the deceased was; and
(ii) how, when and where the deceased came by his death"
Rule 36 of the Rules regulates the scope of inquiry in terms which mirror those of section 11(5)(b):
"(1) The proceedings and evidence at an inquest shall be directed solely to ascertaining the following matters, namely –
(a) who the deceased was;
(b) how, when and where the deceased came by his death; and
(c) the particulars for the time being required by the Registration Acts to be registered concerning the death.
(2) Neither the coroner nor the jury shall express any opinion on any other matters."
Rule 42 further stipulates that no verdict should be framed in such a way as to appear to determine any question of civil liability at all, or any question of criminal liability of a named person.
Rule 60 of the Rules provides that forms set out in Schedule 4 may be used for appropriate purposes with such modifications as circumstances may require. Form 22 is a standard-form Inquisition. The notes to the form (which do not have statutory force) include a list of suggested possible verdicts which may be included in section (4) of the form (Conclusion as to the Death). These are the long-established "short form verdicts", such as "[Deceased] died from natural causes" or "[Deceased] died as a result of an accident".
In R v HM Coroner for North Humberside, Ex Parte Jamieson [1995] QB 1 at 23G-26C, Sir Thomas Bingham MR reviewed these provisions and set out a series of general propositions of law. He described an inquest as a statutory inquiry established to determine the answers to "four important but limited factual questions": who the deceased was, and how, when and where he came by his death. The "how" question was to be interpreted as meaning "by what means the deceased came by his death", a question directed to the immediate physical means of death.
Grounds for judicial review
(1) The verdict
The Claimant's primary ground is that the Defendant should have returned a verdict of suicide. A verdict of suicide would have acknowledged and respected the way in which she chose to end her life, and thus accorded her the dignity to which she was entitled under Article 1 of the Universal Declaration of Human Rights. The Claimant alleges that the verdict was irrational, in the light of the circumstances of her death and the evidence of her suicidal state of mind and behaviour in the period leading up to her death. He also alleges that the Coroner was biased in the sense that he wished to avoid attributing blame to the educational authorities, in particular the head teacher of the school where his wife worked.
The Defendant denies these allegations. He says, in summary, that his task was to ascertain Mrs Lagos' intention at the time of her death. He did take into account the evidence of previous recent attempts to harm herself but looking at the totality of the evidence, he was not satisfied to the required standard that she intended to take her own life. Since he was not satisfied that any other conclusion such as accident or unlawful killing was appropriate, he recorded an open verdict.
I set out below a brief summary of the evidence.
Mr Anele and Dr Pearce described how they had found Mrs Lagos's body. The Defendant read out the statements of the two ambulance staff who were called to the scene, arriving at 7.43 am. Death was confirmed by 7.47 am.
The opinion of Dr Poole, the pathologist, was that Mrs Lagos had died from severe head injuries consistent with a fall from a considerable height (30 to 40 feet) on to a concrete floor. In the course of questioning, Dr Poole confirmed that there was no evidence that the fall had been caused by any illness which caused her to lose consciousness and fall. Nor was there any evidence that she had been attacked.
DC Briars explained that the Barbican is a complex of walkways and apartment blocks on different levels. Mrs Lagos' body was found at the bottom of a deep well. On the walkway above, there was a metal and glass barrier, to stop pedestrians from falling into the well. There were marks on the bar along the top of the barrier which were consistent with someone sitting on the bar with their hands resting on it. Mrs Lagos' fingerprints were found on the bar. Given the height of the barrier and Mrs Lagos' height, it would have taken some effort for her to get on to the barrier.
DC Briars said that there was no evidence of any other person being involved in her death, and no sign of any attack upon her. Taking into account her history of depression...
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