AC-2024-LON-003241 - [2025] EWHC 3014 (Admin)

Under s.1 of the Coroners and Justice Act 2009 (“the 2009 Act”), a senior coroner who is made aware that the body of a deceased person is within their area must conduct an investigation into their death in certain circumstances, including where the coroner “has reason to suspect that the deceased died a violent or unknown death”.

Section 5 of the 2009 Act provides:

“(1)

The purpose of an investigation under this Part into a person's death is to ascertain—

(a)

who the deceased was;

(b)

how, when and where the deceased came by his or her death;

(c)

the particulars (if any) required by the 1953 Act to be registered concerning the death.

(2)

Where necessary in order to avoid a breach of any Convention rights (within the meaning of the Human Rights Act 1998 (c. 42)), the purpose mentioned in subsection (1)(b) is to be read as including the purpose of ascertaining in what circumstances the deceased came by his or her death.

(3)

Neither the senior coroner conducting an investigation under this Part into a person's death nor the jury (if there is one) may express any opinion on any matter other than—

(a)

the questions mentioned in subsection (1)(a) and (b) (read with subsection (2) where applicable);

(b)

the particulars mentioned in subsection (1)(c).”

In determining whether s.5(2) (and the wider investigatory function of a coroner’s inquest it involves) is engaged, it is sufficient that there is arguably a breach of an Article 2 right. In R (Skelton) v HM Senior Coroner for West Sussex [2020] EWC 2813 (Admin), [16], a Divisional Court (Popplewell LJ and Jay J) stated:

“The threshold for the procedural obligation to arise is that there has been an arguable breach of an article 2 substantive obligation. This threshold is a low one because to impose a more onerous burden would run the risk of the coroner determining, in advance of the full evidential picture, what the outcome of any inquest might be. “Arguable” in this context means anything more than fanciful (see R (Palmer) v HM Coroner for Worcestershire [2011] Inquest LR 50 , per Hickinbottom J, at para 60). The threshold was expressed in slightly different language by Lord Burnett of Maldon CJ in R (Maguire) v Blackpool and Fylde Senior Coroner [2021] QB 409, para 75 where he said: “the procedural obligation imposed by article 2 … with which we are concerned [is] the parasitic procedural obligation to investigate when a credible suggestion is made that the state has breached its substantive article 2 obligations.””

Finally, s.10 of the 2009 Act provides:

“(1)

After considering the evidence given to an inquest into a death, the senior coroner (if there is no jury) or the jury (if there is one) must—

(a)

make a determination as to the questions mentioned in section 5(1)(a) and (b) (read with section 5(2) where applicable), and

(b)

if particulars are required by the 1953 Act to be registered concerning the death, make a finding as to those particulars.

(2)

A determination under subsection (1)(a) may not be framed in such a way as to appear to determine any question of—

(a)

criminal liability on the part of a named person, or

(b)

civil liability.

(3)

In subsection (2) “criminal liability” includes liability in respect of a service offence.”