Inquest basics: Challenging a Coroner’s Decision

Inquest basics: Challenging a Coroner’s Decision

In the sixth, and final, article of a series delving into the world of inquests, Charlotte Davies (2007)examines when a decision or conclusion following an inquest can be challenged, and how.

It is sometimes possible to challenge a decision taken by a Coroner, or indeed the conclusion of an inquest, however there is no automatic right to appeal.

A challenge may be made in two ways:

(a)    Applying to the High Court for a judicial review

An application to the High Court for permission to judicially review a decision taken by a Coroner needs to be made as soon as possible following the making of that decision, and within three months at the very latest. The principles upon which the application will be assessed are the same as for any application for judicial review and are concerned with the fairness of the procedure and whether the Coroner properly exercised his or her powers.

(b)    An application under s.13 of the Coroners Act 1988

The timeline for an application pursuant to s.13 of the Coroners Act is not as strict as for judicial review. Such an application can only be brought with the consent, or ‘fiat’, of the Attorney General. If this is refused, there can be no challenge to the Administrative Court: R (Lyttle) v (1) Attorney General (2) HM Senior Coroner for Preston [2018]. Once the consent of the Attorney General has been given, the High Court may order an investigation into the death to beheld by the same or another coroner, or quash the determination or finding of the original inquest, if one has taken place.

To quash the original inquest and order a fresh investigation, s.13 of the Act provides that the High Court must be satisfied that it is necessary or desirable in the interests of justice that an investigation, or another investigation, be held, whether because of fraud, rejection of evidence, irregularity or proceedings, insufficiency of inquiry, the discovery of new facts or evidence or otherwise.

The most notable example of a quashing is of the original Hillsborough inquest findings. In 2012 the Hillsborough Independent Panel published a report which highlighted new evidence relating to the Hillsborough disaster. The court subsequently quashed the original findings and ordered that a fresh inquest should take place.

The following further examples of challenges to Coroners’ decisions are also of interest:

In R (Sturgess) v HM Senior Coroner for Wiltshire and Swindon [2020] EWHC 2007, Dawn Sturgess had died in 2018 after spraying herself with Novichok from a bottle disguised as perfume following the poisoning of the Skripals. The appeal challenged the Coroner’s preliminary ruling to consider only the actions of two Russian nationals and how the Novichok arrived in Salisbury, but not to investigate whether other members of the Russian state were involved, or the source of the Novichok. The court confirmed that Coroners’ obligations do not extend to investigating agents of another state believed to be implicated in the death. In terms of Russia’s responsibility more generally, the court held that an inquest was the appropriate forum to investigate the source of the Novichok and the directions given to the two Russians. Given the Inquest Rules allow for a conclusion of “lawful killing”, the court was “puzzled” by the Coroner’s reluctance to consider the actions of the men on the basis that it could lead to a civil liability determination against Russia. The matter was remitted to the Coroner for further consideration.

In R (Iroko) v HM Senior Coroner for Inner London South [2020] EWHC 1753, the Chief Coroner stated that the court’s role in considering the decision of the Coroner was narrow. Mrs Iroko had died in hospital following cardiac arrest but issues had arisen over the Trust’s Do Not Resuscitate policy. As a preliminary ruling, it was held that there was no evidence that any failure or dysfunction in her treatment was systemic or due to a failure to put in a place a regulatory framework, and as such Article 2 did not apply despite the acceptance that there may have been failings in her care. The court noted deficiencies by hospital staff but was unpersuaded that they cumulatively gave rise to ‘systemic dysfunction’ such as to require an Article 2 inquest and the judicial review was therefore dismissed.

There perhaps appears more of a willingness on the part of the courts to entertain challenges to decisions arising out of deaths that provoke an international interest, rather than those taking place in a medical setting. Whilst it is understandable that greater scrutiny might be expected by the public over the incidents that took place in Hillsborough and Salisbury, where does that leave families who have lost loved ones to the “deficiencies” of our health service?


Charlotte has appeared innumerous multi-day inquests representing all types of interested parties, including Article 2 and jury inquests. She has appeared in a number of inquests reported in the national press, including those involving Leading Counsel. She has particular experience at inquests involving young people taking their own lives.

If you wish to discuss anything in this article or you want to instruct Charlotte you can contact her clerk on


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