Inquest Law Update: Candour, Causation and the Limits of Coronial Language by Charlotte Davies

Inquest law has had an unusually busy spell. The headline development is legislative – the long-promised “Hillsborough Law” remains in the parliamentary pipeline – but the spring of 2026 has also produced a cluster of judgments that practitioners, public authorities and those advising bereaved families will want to have at their fingertips. Several touch directly on questions that recur in the coroner’s court – how far a coroner may explore the counterfactual “what ifs” of causation, where the statutory line falls on critical language in a conclusion, when the Article 2 systems duty is engaged, and the costs consequences of a coroner who claims neutrality while arguing a corner.

The Public Office (Accountability) Bill: paused but due to resume

The Public Office (Accountability) Bill – universally known as the Hillsborough Law – is the single most significant change on the horizon for inquest practice. Introduced in September 2025, it would impose a statutory duty of candour and assistance on public authorities and public officials when they engage with inquiries, inquests and similar investigations, backed by new criminal offences for serious breaches and for deliberately misleading the public. It would also replace the common-law offence of misconduct in public office with modern statutory equivalents.

For coronial work specifically, three features stand out. First, the Bill introduces “parity of representation” for bereaved families, alongside the largest expansion of inquest legal aid in a decade – non-means-tested funding where a public authority is an interested person and represented. Second, it places a duty on public authorities to ensure that their own spend on legal representation at an inquest is necessary and proportionate, with coroners empowered to police that. Third, by amending Schedule 5 to the Coroners and Justice Act 2009, it equips senior coroners with a power to direct compliance from public authorities and officials who are interested persons – subject to Official Secrets Act limits – which sharpens the investigative reach of an inquest.

The important practical point is timing. The Bill has not yet completed its passage. Report stage and third reading were scheduled for January 2026 and then postponed twice, principally over how the duty of candour should apply to the intelligence services. On 27 April 2026 the Commons passed a carry-over motion, so the Bill survives into the new session and, as at the time of writing, is due to resume at report stage with further Government amendments rather than starting again. The duty of candour provisions are widely expected to survive in substance, but the final text – and the commencement timetable – remain to be settled. Anyone advising a public-authority client should be preparing for the cultural shift now rather than waiting for Royal Assent. The direction of travel is already visible, with at least one inquiry chair voicing the candour expectation expressly in a preliminary hearing.

Causation and the danger of dismissing “what ifs” too early

In R (O’Brien) v HM Assistant Coroner for Sefton, Knowsley and St Helens [2026] EWCA Civ 499 (22 April 2026), the Court of Appeal gave useful guidance on causation in deaths where domestic violence is a factor and there has been earlier contact with the police. At first instance the High Court had treated as speculative any attempt to consider what the position might have been had the perpetrator been arrested before the death. The Court of Appeal, in a judgment of Edis LJ, disagreed.

The message is that it is premature to brand a line of enquiry “speculative” before it has actually been explored on the evidence. Where the chain of causation runs through the choices of third parties – including the various decision points of the criminal justice process – a coroner should not assume the answer is unknowable and shut the question down at the outset. The judgment effectively invites coroners and advocates to engage with sentencing and charging frameworks when assessing what would realistically have happened on an earlier intervention. The practical consequence is a potentially wider scope in this category of case, and a higher bar before a coroner can decline to investigate a causative “what if” as inherently speculative.

“Neutral means neutral”: costs and the partisan coroner

The same litigation produced a second instalment on costs: R (O’Brien) [2026] EWCA Civ 605 (19 May 2026). The principle is not new – the Divisional Court said much the same in Worthington in 2018 – but it was obiter there, and the Court of Appeal has now put it beyond doubt. A coroner who answers a judicial review by claiming to be neutral, yet in practice argues the merits, cannot expect that label to shield them from a costs order. On costs, the court will look at how the defence was in fact conducted, not at the description the coroner chose to give it. Edis LJ made the point emphatically. For coroners and those instructed to defend their decisions, the lesson is to choose and commit: either stay genuinely neutral and confine submissions to assisting the court, or contest the claim and accept the costs risk that comes with it.

“Poor” but not negligent: the statutory limits on conclusions

R (Wells Rugby Football Club Ltd and Taunton Rugby Football Club Ltd) v HM Senior Coroner for Somerset (oral permission hearing, Kimblin J, 28 April 2026) is a refusal of permission rather than a substantive judgment – reported so far only through an unapproved note – but it is a useful illustration of how closely the courts scrutinise the words a coroner chooses, and of the latitude that nonetheless remains for critical description falling short of a finding of fault. The death arose from a tragic incident at youth rugby, where a spectator was struck by a ball during a warm-up; because she had aplastic anaemia, the blow proved fatal. The senior coroner returned a narrative conclusion of “accidental death contributed to by poor supervision and spectator safety management”.

The clubs sought permission for judicial review, arguing that the word “poor” crossed the boundary in section 10(2) of the Coroners and Justice Act 2009 by appearing to determine civil liability. Permission was refused. The decision confirms that a coroner may use evaluative, even critical, language to describe how a death came about without thereby determining liability, provided the conclusion stops short of attributing fault in the legal sense. The distinction between describing conduct as deficient and finding it negligent remains a fine one, and the case is a useful peg for advocates on both sides of an argument about the wording of a narrative conclusion.

The Article 2 systems duty: design versus implementation

In R (AH) and R (IS) v Secretary of State for the Home Department [2025] EWHC 3269 (Admin) (Jefford J, 15 December 2025), the court returned to the difficult distinction between a mistake by an individual in working a system – which does not, on its own, establish a systems breach – and a defect in the system itself, which can. The claim arose outside the coronial context, but the reasoning bears directly on the question that recurs in inquests. A sound system operated badly on a single occasion is not, without more, a systems failure.

The judgment’s significant contribution is what it says about implementation. A system may be entirely adequate as designed and still fail because it is not actually put into practice; and a run of individual lapses, rather than being written off as a series of off-days, may itself be the evidence that an adequate design was never being operated as intended. Where the failure lies not in the design of the system but in securing that it is implemented, an Article 2 systems breach may still be established. For inquest lawyers weighing whether a death engages the enhanced Middleton investigation, the lesson is to test not only whether the right policy existed on paper but whether it was genuinely in operation.

The Bench Book and the COVID jury sunset

Two smaller points are worth noting. The Chief Coroner’s Guidance for Coroners on the Bench – the “Bench Book” – was updated on 10 May 2026, including a new section on disputes between family members over the release of a body. The guidance directs the coroner first to establish whether the deceased left a will naming an executor and, if so, to release the body to that executor; where the family is divided, the priorities running through the authorities are to avoid delay and to see the deceased laid to rest with dignity, as in Hartshorne v Gardner.

Finally, the temporary disapplication of COVID-19 as a “notifiable disease” for the purposes of the mandatory-jury provisions in section 7 of the Coroners and Justice Act 2009 expires at the end of 27 June 2026. The disapplication was introduced because COVID-19 is otherwise a notifiable disease under the Health Protection (Notification) Regulations 2010, which would engage the jury requirement in section 7(2)(c). Once it lapses, an inquest opened on or after 28 June 2026 into a death the coroner suspects was caused by COVID-19 may once again attract a mandatory jury, so the position should be checked rather than assumed.

Charlotte has appeared in numerous multi-day inquests representing all types of interested parties, including at Article 2 and jury inquests. She has represented local authorities, police forces and other state agencies, as well as families.  She has appeared in a number of inquests reported in the national press, including those involving Leading Counsel.

If you wish to discuss anything in this article or you want to instruct Charlotte you can contact her clerk on jamie@kbgchambers.co.uk.