Coroners to investigate still born deaths

Inquest proceedings, like other legal proceedings in the UK, have been significantly affected by social distancing restrictions and advice arising from the COVID-19 crisis. This blog looks briefly at the impact of the Coronavirus Act 2020 on proceedings, and examines the Chief Coroner’s guidance notes to coroners working during the crisis.

Inquests are always very sad affairs, and when the court is considering a suicide, it is particularly difficult for the loved ones of the person who has died. 

At the end of the inquest in 2014 into the death of Ella Kissi-Debrah, the coroner concluded that this nine year old girl suffered an asthma attack, followed by a seizure, and died after unsuccessful resuscitation. This is one possible answer to the question of how Ella died. However, there is clearly a bigger question which needs to be answered. 

As we discussed in our recent blog, some inquests will automatically be designated ‘Article 2 inquests’ if the deceased died whilst under the control of the state. Other inquests will only become Article 2 inquests if there is evidence of systemic failures of processes and systems to protect life. Therefore a case of ordinary medical negligence would not trigger Article 2, as confirmed in Parkinson [2018] 4 W.L.R 106.

In June 2018 the government announced that some bereaved families should find it easier to access legal aid funding for representation at inquests. The updated guidance issued by the Lord Chancellor allows caseworkers to waive the financial means test “for cases where the state has a procedural obligation to hold an inquest under Article 2”. 

In February 2019 in its Final Report on the Review of Legal Aid for Inquests, the Ministry of Justice confirmed that it would not be introducing automatic public funding for families at inquests where the state is legally represented. This is hugely disappointing news for families, such as the family of PC Palmer, who have experienced the reality of an inquest where the state has the benefit of a highly experienced and well-resourced legal team while they are left to try and find lawyers prepared to represent them for free.

The husband and children of the school teacher, Ann Maguire, who was murdered by a pupil, William Cornick, in her classroom in April 2014 have been unsuccessful in their attempt to appeal against the decision of the High Court to dismiss their claim for judicial review of a decision of the Assistant District Coroner for West Yorkshire. 

Today, the Health Secretary announced “a new maternity strategy to reduce the number of stillbirths. This strategy centres on the investigation of still birth deaths by the new Healthcare Safety Investigations Branch but it also included a planned change in the law to allow coroners to investigate full term still birth deaths. Currently there is no requirement for a doctor to refer a still birth death to the local coroner.

In the recently reported case of R (Silvera) v HM Senior Coroner for Oxfordshire [2017] EWHC 2499 (Admin), the Divisional Court looked at the investigative duties placed on the state by Article 2 of the European Convention on Human Rights and the importance of the coronial process in ensuring that those duties have been met.

The recent decision of Mr Justice Holroyde in R oao Donald Maguire and ors v The Assistant Coroner for West Yorkshire (Eastern Area) [2017] EWHC 2039 provides a salutary reminder of just how difficult it is successfully to judicially review the ‘case management’ decisions of a coroner – in this case a decision as to which witnesses to call at an inquest – and of the costs risks of bringing such a challenge.