Coroners have a wide discretion to decide whether or not events preceding a death fall within the scope of an inquest, but how should they go about making that decision?
The recently published case of Sharon O'Brien v HM Assistant Coroner for Sefton, Knowsley and St Helens helps shed light on this by focusing on the distinction between 'possible' and 'speculative' links between the event in question and the death.
In this briefing, we look at what the court found in this case and its practical impact.
What was the inquest about?
The deceased, Linda O'Brien, died after falling from the fourth floor window of her flat.
Approximately 7 months prior to this, a man Linda had previously been in a relationship with, Alan McMahon, had been sentenced to 22 weeks' imprisonment for assaulting Linda. He was also made subject to a restraining order, preventing him from approaching, contacting or communicating with her for 5 years.
However, about a month before Linda's window fall death, the police had received an anonymous report of a domestic violence incident at her flat. When they attended, Mr McMahon was at the flat with Linda, but she was calm and said she did not know why the police had been called. None of the police officers who attended were aware that Mr McMahon was the subject of a restraining order, despite checking on relevant police databases. Their evidence was that, had they known he was in the flat in breach of the restraining order, they would have arrested him. Although the existence of the restraining order subsequently came to light and steps were being taken towards prosecuting him for breaching this, Linda's death intervened.
Emergency services were alerted to Linda's fall from the window by Mr McMahon, who was the only other person in the flat with her at the time. Post mortem showed evidence of assault injuries sustained prior to her exiting the window. Mr McMahon was later sentenced to 20 months' imprisonment for multiple breaches of the restraining order and for theft. An accusation of murder was not proceeded with.
What was the Coroner's decision on scope?
It is important to flag first that Article 2 was found not to be engaged in this case, meaning there was no requirement here for an enhanced investigation looking at the wider circumstances of the death, as would be the case for an Article 2 inquest.
It was nevertheless argued on behalf of the deceased's family that the police's conduct in failing to identify the existence of the restraining order at the time of the reported domestic violence incident should be included within the scope of the inquest because, had Mr McMahon been arrested and prosecuted for breaching the restraining order, it is possible that he would not have been in Linda's flat on the day she died and the death would not have occurred.
The Coroner decided, however, that there was no 'coronial causation' linking the police's conduct with events resulting in the death because, to meet the causation test, the event or conduct in question needs, on the balance of probabilities, to have more than minimally, negligibly or trivially contributed to the death (i.e. it needs to have made an actual or material contribution to the death). In this case, the Coroner found, it simply could not be known - and was therefore pure speculation - whether arresting Mr McMahon at the time of the reported domestic violence incident would have prevented him being present at Linda's flat over a month later when she died (or indeed whether his presence there was causative of the death). As such, the Coroner concluded that events surrounding the reported domestic violence incident and the attending police being unaware of the restraining order would not require extensive investigation at the inquest and mention of those would be just for background purposes and information.
The deceased's family challenged this decision by way of judicial review, arguing that the Coroner had unlawfully limited the scope of the inquest by finding there was no causal link between the death and the acts or omissions of the police.
What did the High Court decide?
In summary, the High Court found in favour of the Coroner by ruling that, whilst is it is possible that, if Mr McMahon had been arrested for breach of the restraining order before Linda's death, he might have been in prison on the date of her death and it is possible that her death would not have occurred, whether he would have been in custody on that date is "entirely speculative". It was not enough to show that a particular event, or particular conduct, deprived the deceased of an increased chance of life (following the explanation in Tainton).
The judge did not believe it would be possible to obtain reliable evidence that would enable the Coroner to be satisfied on the balance of probabilities that Mr McMahon would have been in custody on the date of Linda's death had he been arrested earlier. It followed that any failure to arrest him prior to that date could not be proved to have contributed more than minimally, negligibly or trivially to the death. In the absence of this causative link, the proposed investigation into the actions or omissions of the police was found by the Court to be irrelevant, because it could not be proved on the balance of probabilities that anything done or not done by police officers at the time of the reported domestic violence incident or subsequently more than minimally, negligibly or trivially contributed to Linda's death.
The High Court also took the opportunity to highlight what the Court of Appeal said in the case of Morahan about inquests being an "inquisitorial and relatively summary process" and "not a surrogate public inquiry", concluding that a decision to limit the scope of the enquiry to avoid an expensive and time-consuming investigation into the acts or omissions of the police was consistent with the purpose of an inquest and could not be said to be irrational.
Practical impact and what next?
The reality is that Coroners have a wide discretion to decide on the scope of an inquest and delving into the intricacies of the law on coronial causation may not always be enough to persuade a Coroner that a particular event/conduct which is of concern to the deceased's family is outside the scope of an inquest. However, where the link between a particular event/incident and the death is felt to be merely 'speculative', this may be a useful case to draw to the attention of the Coroner when making submissions about what should or should not fall within scope.
The High Court's decision in this case may, however, not be the final word here because we understand that an application has been made for permission to appeal to the Court of Appeal. There is accordingly an element of 'watch this space' on this and we will continue to keep you updated.
How we can help
Our large national team of inquest lawyers have a wealth of experience in supporting providers and individuals across the health and social care sector through the inquest process - from relatively straightforward hospital deaths to very complex Article 2/jury inquest cases involving multiple parties and deaths in state detention, including providing representation at pre-inquest review hearings when matters such as inquest scope are decided.
