Mays v HM Senior Coroner for Kingston Upon Hull & East Riding of Yorkshire [2021] EWHC 3604 (Admin)

Earl v HM Senior Coroner for East Sussex [2021] EWHC 3468 (Admin)

R (on the application of Ginn) v HM Senior Coroner for Inner London [2022] EWHC 28 (Admin)

Three recent applications by bereaved families have resulted in fresh inquests being ordered by the High Court or Divisional Court. Each case offers some helpful guidance on how coronial investigations and inquests should be conducted.

Fresh evidence: Mays v HM Senior Coroner for Kingston Upon Hull & East Riding of Yorkshire [2021] EWHC 3604 (Admin)

This case concerned an Article 2 inquest into the death of 22-year-old Sally Mays. The Coroner identified a number of failings including a refusal to admit her to an acute inpatient psychiatric ward. Those failings constituted neglect and caused or contributed to her death later that same evening.

There was no criticism of the way in which the Coroner conducted the inquest. Rather, after the inquest concluded, the Coroner was informed for the first time that there had been a conversation between a Community Psychiatric Nurse and a Consultant Psychiatrist in a carpark, shortly after the inpatient admission was refused. This information had been intentionally withheld from the Inquest; a police investigation concluded there was insufficient evidence to prosecute because the information was withheld because it was considered not clinically relevant, rather than an intention to pervert the course of justice.

The outcome of the inquest was unlikely to be substantially affected by evidence about this conversation – the Coroner already found numerous failings which constituted neglect. But this was an Article 2 inquest and there had been no fact-finding investigation into this conversation and whether it was an opportunity to reverse the poor assessment decision and admit Ms Mays to the unit. The fact that this point had not been explored by the inquest meant the Article 2 investigative obligation had not yet been discharged and a fresh inquest was ordered.

Insufficiency of inquiry: Earl v HM Senior Coroner for East Sussex [2021] EWHC 3468 (Admin)

This application concerned an inquest into the death of Jessie Earl, a 22-year-old who went missing in May 1980 and whose remains were found 9 years later. The circumstances in which her remains were found – in an almost inaccessible area and without any of her property other than a tightly knotted bra – did not result in a full murder investigation. A subsequent police inquiry found that the police investigation at the time was flawed and inadequate. On the basis of that investigation, the Coroner reached an ‘open’ conclusion at the inquest.

It was not simply the case that the police investigation was flawed and inadequate, although the Coroner was clearly not assisted by such an unsatisfactory investigation. The Coroner’s decision to reach an ‘open’ conclusion was unreasonable under public law principles: the circumstances in which she was found clearly indicated that this was likely to be an unlawful killing and, furthermore, there were irregularities in the inquest proceedings.

The Court recognised the family’s lengthy pursuit of justice, and a fresh inquest was ordered, in large part because the Court felt it had to do its best to put right an injustice for the family and maintain public confidence in the coronial process.

Inadequate directions to jury: R (on the application of Ginn) v HM Senior Coroner for Inner London [2022] EWHC 28 (Admin) 11 Jan 2022

While the information which fed into the investigation was inadequate in the other two cases, this was a case where it was the Coroner’s errors which undermined the inquest process and required a fresh inquest to be ordered.

The inquest concerned the suicide in custody of Richard Ginn, a 56-year-old prisoner with a history of recurrent depressive disorder and emotionally unstable personality disorder. Despite submissions from the Interested Persons, the Coroner decided not to give the jury any written directions, a questionnaire or a list of issues to consider.

In circumstances where the Chief Coroner’s Guidance No. 17 on Conclusions strongly encourages coroners to give jurors written directions in complex cases, the Court clearly thought that this was a poor decision. But it was not a public law error.

However, her guidance on the jury’s task did fall into error. Notably, she failed to direct the jury that they were required to make a determination on whether the core issues which were raised during the inquest caused or contributed to Mr Ginn’s death. As this was an Article 2 inquest, the investigative obligation would only be satisfied if the jury reached a conclusion on the disputed factual issues at the heart of the case. Instead, her guidance gave the impression that there was no need for them to make determinations on the central issues. As a result, the jury returned a meaningless conclusion and a fresh inquest was ordered.


These cases are all instructive. Mays and Earl are both indicative that coronial investigations are always more effective when there is careful, considered and appropriate engagement with the inquest, from police officers or clinicians who are involved in the circumstances of the death or the investigation thereafter. Withholding information – whatever the motivation – is damaging to justice, and to the trust of the public in the coronial process. Also, it is unlikely to be advantageous in the long run.

But coroners cannot hide behind the inadequacies of the investigation of others. Their investigation must be full, frank and fearless. Even if a police investigation, or a Trust’s serious incident report, does not properly grapple with the key issues, it is incumbent on a Coroner to initiate investigations to satisfy him or herself that their statutory duty is complied with.

That duty encompasses an obligation on a Coroner to elicit a jury’s conclusions (or set out their own conclusions) on the key issues in the case. That is essential in order to comply with the investigative duty under Article 2 but likely to be necessary in traditional Jamieson inquests anyway. Coroners would be sensible to follow the Chief Coroner’s guidance that they should give clear, written guidance on the law to juries, whose conclusions can otherwise betray a lack of understanding of the proper scope of their role.