HM Senior Coroner for Gwent, Re Inquest into the Death of Vaughn, Re [2020] EWHC 3670 (Admin)

A fresh inquest was ordered by the High Court in circumstances where the Deputy Coroner had been unaware of the presence of a suicide note which later came to light.


In April 2014, the Deceased was found alive but unresponsive at his home. He had taken a large quantity of paracetamol. He was taken to hospital but sadly died. A mental health team leader who had been treating him for some time attended the property and found a suicide note. He gave the note to the Deceased’s brother, to whom it was addressed, and retained a copy and put it with the Deceased’s medical records.

An inquest then took place before the Deputy Coroner in 2015. The Deceased’s brother expected the mental health team leader to include a reference to the suicide note in the report to the Coroner. However, for reasons of failed process or procedure, that did not happen. The Deputy Coroner was therefore not aware of the existence of the note at the time of the inquest and returned a conclusion of misadventure.

Immediately after the inquest, the brother challenged the Deputy Coroner as to why no mention had been made of the suicide note. The brother requested that an inquest was re-opened. Unfortunately, the High Court noted, this was followed by a period of two years before anyone acted on the request. In 2018, the Attorney-General’s office issued a fiat but its authority lapsed as no claim form was filed with the Administrative Court. A further fiat was requested in July 2019 and granted in August 2020.


Section 13 of the Coroners Act 1988 provides that:

“This section applies where, on an application by or under the authority of the Attorney General, the High Court is satisfied as respects a coroner (“the coroner concerned”) either-

(a) that he refuses or neglects to hold an inquest or an investigation which ought to be held; or

(b) where an inquest or an investigation has been held by him, that (whether by reason of fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, the discovery of new facts or evidence or otherwise) it is necessary or desirable in the interests of justice that an investigation (or as the case may be, another investigation) should be held.”

The High Court noted that the test in section 13(b) is in the alternative, such that (emphasis added) “if it can be shown that a fresh inquest is either necessary or desirable, then it will be ordered” [16].  It further noted the court’s treatment of s.13 in Attorney-General v Her Majesty’s Coroner for South Yorkshire [2012] EWHC 3738 (Admin), where the Lord Chief Justice said:

“The single question is whether the interests of justice make a further inquest either necessary or desirable. …it seems to us elementary that the emergence of fresh evidence which may reasonably lead to the conclusion that the substantial truth about how an individual met his death was not revealed at the first inquest, will normally make it both desirable and necessary in the interests of justice for a fresh inquest to be ordered… If a different verdict is likely, then the interests of justice will make it necessary for a fresh inquest to be ordered, but even when significant fresh evidence may serve to confirm the correctness of the earlier verdict, it may sometimes nevertheless be desirable for the full extent of the evidence which tends to confirm the correctness of the verdict to be publicly revealed.”

The High Court considered that on the facts of the case it was not necessary to order a fresh inquest, noting that the Coroners Service in Gwent had allowed a long time to pass without any, or any proper, explanation for the delay, with the record showing that the deceased’s death was attributable to misadventure. During that period they had only sporadically suggested that the inquest should be reopened [17].

However, the Court was “easily persuaded” that a fresh inquest was desirable, principally because of the wishes of the deceased’s brother [18]. Further, having belatedly been provided with the suicide note and read it, the court held that a different conclusion was indeed likely [19].


This is a short but important judgment which serves as a useful reminder of the nature of the statutory test for ordering a fresh inquest – namely, that a fresh inquest will be in the interests of justice if it can be shown that it is either necessary or desirable. In interpreting the “desirable” limb, the High Court places significant weight upon the family’s wishes even in circumstances where it did not consider that it was “necessary” to hold a fresh inquest.

It is interesting that the court held that, having read the suicide note, a different conclusion was likely, thereby giving a second reason why a fresh inquest was desirable. The proper interpretation of a note found with the deceased, and its probative value, is usually a matter for the coroner having considered all the evidence before them. Here, the High Court seems to stray into pre-judging this issue by referring to the note as a “suicide note” and holding that a different conclusion was likely.

Overall, the judgment gives practitioners seeking a fresh inquest a clear and concise statement of the law and guidance as to how it will be applied.