R (Sutovic) v HM Coroner for Northern District of Greater London

Lord Justice Moses handed down the following judgment of the court:

Introduction

On 27 January 2004 the claimant's son, Petar Sutovic, died in a flat in Belgrade, Serbia. He was aged only 24. His mother is a solicitor in London. Her son was a British citizen. Since the body of Petar Sutovic was returned to the district of the North London coroner he assumed jurisdiction once the presence of the body in his district was reported to him (Section 8 of the Coroners Act 1988 and R v West Yorkshire Coroner, ex p. Smith [1983] 1 QB 335).

On 27 September 2004 the coroner returned an open verdict. The injury causing death was described as:-

"Morphine poisoning".

Under the heading:-

"Time, place and circumstances at or in which injury was sustained",

the coroner recorded:-

"In the early hours of 27 January 2004 the deceased was seen, lifeless at his mother's flat in Belgrade. There was no evidence as to the exact circumstances surrounding the death. He had previously been a drug abuser but his mother said that recent drug screens were negative."

There are two sets of proceedings which we have heard at the same time. Firstly, the claimant seeks judicially to review the coroner's verdict on the grounds of procedural irregularity and insufficiency of enquiry. This claim was issued on 1 December 2004. Secondly, she brings an application pursuant to Section 13 of the Coroners Act 1988. The Attorney-General's consent was granted on 15 April 2005 and this claim was issued on 25 May 2005. The claimant contends, that as a result of evidence which she has now obtained it is both necessary and desirable, in the interests of justice, that another inquest should be held. There is a real possibility that a different verdict could be reached.

Because it might appear, during the course of this judgment, that we are being unduly critical of the claimant it is necessary to say something about the circumstances in which she brings these proceedings, at the outset. It is not possible for this court to share in her grief nor fully to comprehend the impact it must have on her, faced with the loss of her young son. We can only express sympathy and attempt to show understanding. But the undoubted grief which she has suffered has had a substantial impact upon the conduct of this case. With the benefit of counsel, and in particular the coroner and his counsel, Mr Beer, we have been able to focus upon issues of substance which the vast body of material with which we were supplied threatened to overwhelm. Although we have been able to focus upon specific issues on which Mr Lissack QC, on behalf of the claimant, wisely concentrated, it is necessary to record that the coroner has been faced with unceasing and in many cases unwarranted accusations. Some have been withdrawn, others have been left in the air, many are without foundation. The claimant, in her grief, has, understandably, been unable to conduct this litigation with any sense of proportion. We shall endeavour to do so by concentrating on issues that seem to us to be worthy of consideration and relevant to our conclusions. That does not mean that we have not considered everything else which has been laid before us. Nor should it be overlooked that a large number of grounds and accusations have at one time or another been advanced and then either withdrawn or left in the air. The coroner has borne the brunt of this approach with a proper sense of neutrality and dignity.

Events leading to the inquest

On 27 January 2004 the claimant's son died in his flat in Belgrade, Serbia. On the same date, 27 January 2004 a junior ensign, Boris Mitrovic, wrote a report. In the first paragraph it said:-

"The death was most probably caused by an overdose of narcotics."

The report continues by recording that the death was established at 2.56am by a physician on duty, Dr Zivanovic, pursuant to the order of an investigation judge. The report says that the entrance door of the flat was locked and sealed and that the key of the flat was placed with the Secretariat of General Administration. The report continues:-

"On the spot was interviewed the deceased's friend, Sergej Nesic… has known the deceased who used to visit the place as a guest. He further declared that starting from two weeks ago he has lived at the deceased's place and that he had to agree with the deceased to continue living there as a sub-tenant. According to Nesic, the deceased was a treated drug addict; however, three days ago when he came from work he found the deceased in the flat who according to his physical aspect and behaviour gave an impression of a man under the effect of drugs and, therefore, he, Nesic, concluded that the deceased started to be on drugs again and added that on 26 January, around 11.20pm Sutovic came to the flat where already were Sergej Nesic and a friend of both of them. Zoki Cupac, a citizen of Australia…on which occasion, after dinner, Sutovic went to his room leaving the two of them alone, and when on 27 January about 2.30am Nesic entered his room you found him dead and with the tools for drug administering beside him, which was confirmed by Cupac when he was interviewed.

In the interview held with the patrol on duty of this Internal Affairs Unit, these two persons confirmed that when coming to the spot they saw a syringe and a needle stuck in the deceased's left arm, which fell out while paramedics were rendering aid to the deceased.

A crime-laboratory technician, Emus Ranko, inspected the body on the spot from which he took one used syringe with a needle, three more needles, one metallic spoon, two foils from cigarette boxes with the traces of brown powder on them, and two halves of tablets of the same colour, which will all be forwarded to OKT."

The following day an autopsy was conducted at the Institute of Forensic Medicine. The report is dated 28 January 2004 and signed by four pathologists. The report contains a chemical toxicological analysis of internal organs and biological fluids. It explains the method by which the analysis was made. It records a number of external findings which include what are described as "several circular openings" with mildly bruised edges and sides continuing into the subcutaneous soft tissue in the left elbow and below it. It describes in the ulnar area of the left forearm the skin as being bluish purple with hematoma (sic) and an opening with flat mildly bruised edges and sides continuing with a channel to the subcutaneous soft tissue. It records that there was no foreign matter in the ears, nose, or mouth but dark grey dry matter in the nostrils and round the mouth edges. It records the clothing as being a white T-shirt, green jeans, black socks, black underpants, black high winter shoes with shoelaces. In relation to the internal examination, examination of the head and skull showed no injury and no fractures. The conclusion was recorded as:-

"A violent death, caused by intake of drugs."

The reference to violent death, it was agreed, signified no more than that which follows, namely, intake of drugs.

The claimant had always remained in a very close relationship with her son. He was extremely intelligent. Unfortunately he was, whilst a student, diagnosed as diabetic. In 2000 he suffered a serious injury when he was knocked down by a lorry. At some stage, it appears he became addicted to heroin although in the period before his death the claimant was satisfied that he had managed to rid himself of the habit. Information received after the inquest may (see paragraph [67]) suggest her confidence was misplaced. She speaks of a telephone call on 23 January 2004 when he appeared agitated as a result of a visit by the police. Nothing turns on this for the purposes of these proceedings but the incident clearly fuelled the claimant's suspicions.

She learnt of her son's death on the telephone in the early hours of 27 January 2004 from a relative. On the morning of the same day she spoke to Nesic. Although the conversation has, similarly, fuelled her suspicions it is unnecessary to relate his account for the purposes of these proceedings. Of greater relevance are her conversations with the housekeeper of the flat who had apparently been working for the family for a substantial period. Two pieces of information obtained from conversations with the housekeeper are relevant. But we are unclear as to the precise date of those conversations. This may partly be a result of the fact that certain exhibits have been lost by solicitors, previously instructed by this claimant. During the course of a conversation with the housekeeper which was recorded, the claimant and the housekeeper, Vesna Vesalinovic, discussed what appeared to the housekeeper to be substantial blood on part of the clothing of Petar Sutovic and on the bedclothes. Further, it seemed to the housekeeper that someone had beaten him up. She is recorded as saying:-

"His nose does not resemble…he does not look himself."

It is important to note that the claimant responded:-

"But when I saw him after two days, when he arrived here, his face was totally normal…nothing swollen, nothing, nothing."

The claimant repeated...