Challenging the Outcome of an Inquest
Wedlake Bell LLP recently acted for the successful Applicant in the case of Cherfan v HM’s Senior Coroner for West London [2024] EWHC 361. This case serves as a reminder that adopting a neutral approach will not guarantee protection on costs for a Coroner and emphasises the wide discretion of the Court in this respect. The full judgment can be found here.
Background
We were instructed by the father of the late Marc Cherfan, who tragically died at home in September 2022 aged 38. Given that his passing was both unexpected and unexplained, an investigation was launched to establish the circumstances of his death. It was found that Marc died as a result of an overdose of his prescription medication.
The Coroner’s Office subsequently contacted our client and his close family members to confirm that an inquest would be opened. At this time, the family made it clear that they were confident the overdose was accidental. This view was supported by the fact that Marc’s GP recorded in recent months that he did not present with any thoughts of self-harm or suicide, a sentiment which Marc’s close family agreed with. There was also circumstantial evidence which suggested that this was an accidental death. For example, and as highlighted within the judgment, (i) the positioning of blood staining close to Marc’s front window may suggest he was trying to seek help from a passerby, (ii) a line of cannabis on the table suggests he was in the process of planning some form of activity prior to taking his medication and, (iii) there was a blood stained cushion cover in the washing machine which suggests Marc intended to do his laundry.
In addition to confirming their view that Marc’s death was accidental, his family also stated the following to the Coroner via email, “We do not see the point of an inquest… Marc is gone and nothing will bring him back.” It appears this may have been the basis for the Coroner’s decision to hold an inquest in writing (an inquest without a hearing and with no attendees) however, Marc’s family were not notified of this decision. They also were not notified of the date or time that the inquest was due to be held.
An inquest in writing did not ultimately take place due to an IT issue in the Coroner’s office; accordingly, the inquest was converted to a documentary inquest at the last minute – a further development that Marc’s family were not notified of.
After a brief inquest lasting just 8 minutes, the Coroner returned a conclusion of suicide; a finding which Marc’s family strongly refuted.
The Claim
We, on behalf of Marc’s father, commenced an application to challenge this decision pursuant to section 13 of the Coroner’s Act 1988. Such a process is not straightforward; in order to challenge the decision of a Coroner, it is first necessary to seek permission from the Attorney-General. Permission was obtained and the Attorney-General granted their fiat, which gave our client standing to bring the challenge.
The challenge to the decision was brought on the basis that there had been an irregularity of proceedings when the Coroner’s Office failed to notify Marc’s family of the inquest date (as required by the Coroner’s Rules 2013). Accordingly, it was submitted that the interests of justice require a fresh hearing to take place. It was also highlighted that the Coroner failed to comply with the Chief Coroner’s Guidance in relation to the decision to hold the inquest in writing (and the decision to convert it to a documentary hearing). Such inquests are only suited to “straightforward and uncontentious cases” with “no real prospect of disagreement”; given that Marc’s family had already made it clear that they considered this to be an accidental overdose, it should have been evident that there was a prospect of disagreement.
A letter of claim was sent to the Coroner in December 2023. Within this letter, we invited the Coroner to make her own application since the central failure was an administrative error by her service. The Coroner responded stating that she would not oppose the application but declined to make it herself, instead adopting a neutral stance. Unfortunately, the Coroner also declined to sign a proposed consent order which would have avoided the need for a Court hearing. Whilst the Coroner was entitled to adopt a neutral approach, we considered this an unreasonable stance given that the failures by the Coroner’s Office were uncontested.
Judgment
The Court ordered that the Coroner’s decision be quashed. They also ordered that a fresh inquest should take place before a new Coroner.
Whilst the Court recognised the significant pressure faced by Coroners, they held that the multitude of errors should have been obvious to the Coroner in this case. Specifically, the Coroner should have ensured that Marc’s family were notified of the date/time of the inquest. Additionally, the decision to hold an inquest in writing was flawed as, again, the family were not notified of this, nor were they invited to make representations. These irregularities were compounded by the Coroner’s decision to hold a documentary hearing, which she was not entitled to do in the circumstances.
The Court also ordered that the Coroner make a contribution of £20,000 towards our client’s costs.
Costs
The usual starting point in cases such as this is where a Coroner adopts a neutral position within proceedings, the Court will not make an order for costs against them. This was confirmed as the established principle in the case of R (Davies (No.2)) v HM Coroner for Birmingham [2004] EWCA Civ 207. As a result, it is perhaps unsurprising that many Coroners will take a neutral stance when faced with a challenge to a decision.
In this case, the Court held that it would be “unjust for the financial burden to fall entirely on the applicant“, recognising that a successful applicant should be able to recover costs if the Coroner has made errors in law, rather than having to fund the case entirely from their own resources. The Court highlighted that the case of Davies “does not lay down cast iron rules“, highlighting to Coroners that a neutral approach may not be the best one in circumstances where errors have undoubtedly been made.
Observations
This case serves as a reminder that Coroners should review the specific facts of each challenge before deciding whether it is appropriate to adopt a neutral approach. Failing to do so could result in unwanted cost consequences. This case also highlights that such proceedings should be managed carefully and proportionately; it is therefore imperative that specialist advice is sought by a potential applicant at the outset of any challenge.
Helena Fairley and Andrew O’Keeffe of Wedlake Bell’s Private Client Disputes team represented the successful Applicant in this matter. Sebastian Naughton of Serjeant’s Inn appeared on behalf of the Applicant.