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Inquests and Coroners

Some of the legislation

Coroners and Justice Act 2009
Coroners (Amendment) Rules 2005
Coroners (Amendment) Rules 2004
Access to Justice Act 1999
Coroners Act 1988
Coroners Rules 1984

Some of our recent notable cases and inquiries

Re. Jake Hardy (2014)
Devastatingly critical verdict in the inquest into the death of Jake Hardy, a highly vulnerable young person who hanged himself after staff failed to protect him from being constantly bullied in HMPYOI Hindley.
Verdict given on 4/4/2014
Dexter Dias QC & Richard Reynolds

Mark Duggan (2014)
Inquest into the death of Mark Duggan who was shot and killed by V53, a Metropolitan Police firearms officer, in Tottenham in August 2011. At the end of an inquest lasting more than three months, and after deliberating for seven days the jury concluded that Mark Duggan was lawfully killed.
Verdict on 8/1/2014
Leslie Thomas QC

Re. Peter Barnes (2013)
Jury found that systemic neglect contributed to death at private psychiatric hospital Cygnet Hospital in Wyke. It was concludud that Peter took his own life while the balance of his mind was disturbed, contributed to by neglect and inadequate systems.
Verdict on 6/11/2013. Bradford Coroners Court
Tom Stoate

Re Jimmy Mubenga (2013)
A verdict of unlawful killing in the inquest into the death of Jimmy Mubenga. Mr Mubenga died of positional asphyxia in October 2010 in the custody of G4S security guards while being deported from the UK to Angola.
Verdict given 9/7/2013
Henry Blaxland QC

Re Kua (2012)
Mother and five children killed by fire in home caused by failure of freezer component. A narrative verdict was given and Rule 43 Report at the inquest. The tragedy was described by the London Fire Brigade as the worst house fire they had seen in the last decade.
North London Coroner’s Court 25/10/12
Ali Bajwa QC and Deirdre Malone

Sean Rigg (2012)
Highly critical narrative verdict highlighting failures by both the police and the mental health services regarding the death of a man in police custody at Brixton Police Station in August 2008 after prolonged restraint.
Southwark Crown Court 1/8/2012
Leslie Thomas QC

R (Mack) v HM Coroner for Birmingham (2011)
Successful appeal to the Court of Appeal in a judicial review claim against a coroner. Obtained a fresh inquest in a case of a death in hospital from clostridium difficile, against a background of serious medical failings.
[2011] EWCA Civ 712 10/5/2011
Stephen Simblet

Adam Rickwood (2011)
Damning narrative verdict criticising failings by Serco, the private company running Hassockfield, the Youth Justice Board, Prison Service restraint trainers and the Lancashire Youth Offending Team where unlawful methods of restraint had led to the death of a 14 year old boy.
Verdict given 28/1/2011
Rajiv Menon QC

Eliud Nyenze (2010)
Inquiry into the death of Eliud Nyenze at Oakwood Immigration Detention Centre in April 2010. The 39 year old asylum seeker was refused medicine shortly before his death. His death subsequently led to rioting and the closure of the Centre.
Verdict given October 2010
Kirsten Heaven

Rachael Stubbs (2010)
Defective monitoring of patients at the Meadow Unit, Cheadle Royal Hospital led to the death of patient. Deputy Coroner criticised failure to carry out ‘level 4’ continuous observation appropriately, failures of record-keeping and failure to carry out CPR immediately.
Verdict given 14/7/2010
Stephen Simblet

R (Humberstone) v Legal Services Commission (2010)
Successful judicial review of the Legal Services Commission’s refusal to fund the mother of the deceased at an inquest. This case has been the subject of considerable comment in the legal press.
[2010] EWHC 760 (Admin) 13/4/2010. Reported at [2010] ACD 51.
Stephen Simblet

Paul Clarkson (2009)
Recalled prisoner was provided with inadequate ongoing care and support due to failures at HMP Leeds, the Probation Service and Mental Health Inreach Team.
Verdict given 18/11/2009
Kirsten Heaven

Kerry Devereux (2009)
An inquest jury concluded that neglect and system failure contributed to the self-inflicted death of Kerry Devereux at HMP Foston Hall. Kerry was found hanged in the segregation unit of the prison on 18 April 2007.
Verdict given 21/10/2009
Kirsten Heaven

Mohammed Muhir (2009)
An inquest jury concluded that a catalogue of serious failings at HMP Leeds caused or contributed to the death of 25 year old remand prisoner Mohammed Mudhir who was found hanged in the segregation unit of the prison on 21 August 2005 while the balance of his mind was disturbed.
Verdict given 25/3/2009
Leslie Thomas QC

Michael Bailey (2009)
Judgment gave a damning indictment of the private prison system where a mentally ill person had been left in a cell at a time of great vulnerability and subsequently was found hanging in the segregation unit at HMP Rye Hill on 24th March 2005.
Verdict given on 9/2/2009
Leslie Thomas QC

R (on the app. of Selina Warren) v HM Assistant Coroner for Northamptonshire (2008)
Coroner had been wrong not to call a consultant psychiatrist, and in not doing so had failed to comply with Article 2 of the ECHR.
[2008] EWHC 966 (Admin) 29/4/2008
Sadat Sayeed

Gareth Myatt (2007)
Landmark inquest into the death of Gareth Myatt, the youngest child to die in police custody and the only child to die following restraint.
Verdict given 28/6/2007
Dexter Dias QC

R (on the app of Helen Cash) & HM Coroner for the Coutny of Northamptonshire (2007)
A coroner’s decision not to permit an inquest jury to consider a verdict of unlawful killing or to leave a narrative verdict to the jury was wrong. A fresh inquest before a different coroner and jury ordered.
[2007] EWHC 1354 (Admin) 8/6/07. Reported at (2007) 4 All ER 903.
Stephen Simblet

Shahid Aziz (2007)
Inquest into the death of Shahid Aziz who was killed in prison by his cellmate Peter McCann in 2004.
Verdict given 17/5/2007.
Leslie Thomas QC

Zahid Mubarek Inquiry (2006)
First judicial public inquiry following a death in custody and perhaps the most important public inquiry investigating the State’s Article 2 protection of Right to Life obligations. 186 failures in Prison Service exposed; 88 recommendations for far-reaching change made in Inquiry Report.
Dexter Dias QC

Dawson & Dunn v HM Coroner for East Riding and Kingston upon Hull (2001) (no link)
Challenge to inquest verdict involving questions of bias
[2001] EWHC Admin 352 9/4/01. Reported at (2001) ACD 365
Colin Hutchinson

R (on application of Scott) v HM Coroner for Inner West London (2001)
Obtaining a new inquest where a psychiatric patient detained in prison had been allowed to hang himself and the issue of “neglect had not been considered. The new inquest ordered returned a verdict incorporating “neglect.
[2001] EWHC Admin 105 13/2/01. Reported at (2001) 165 JP 417 and (2001) 61 BMLR 222
Stephen Simblet

R v HM Coroner for Coventry ex parte Chief Constable of Staffordshire (2000) (no link)
Supporting an inquest jury’s verdict of neglect following death in custody
5/7/00. Reported at (2000) 164 JP 665
Stephen Simblet

Useful links

Coroner Service Guidance (Ministry of Justice)
Guides to Coroner Investigations and Services (gov.uk)
Coroners Division (Guide to Coroners and Inquests)