Coronial and Inquests Law

Coroners Court

Coroners are independent judicial officeholders. Investigates and explains deaths: violent or unnatural, unknown or deceased died in state detention. Coroners are supported by Coroner’s officers who are usually employed by either the local police service or local authority.?

TYPE OF INQUESTS:

1. Jamieson Inquest - known not intended to establish blame. But to provide clarity as to how the deceased came to their end.
2. Middleton or Article 2 Inquest - enhanced form and held that the state or its agents have failed to protect the deceased against human threat or other risks. Death in custody.?

Coroner’s and Justice Act 2009

Establish an effective, transparent, responsive justice and coroner service. Updating the criminal law, introducing a consistent and transparent sentencing framework. Improve the service of bereaved families.?

PART ONE: Certification and registration of deaths by the Coroners. Investigations into death include the general duty of a senior coroner to investigate deaths. Appointment of coroners and coroner areas. Provisions into investigations and deaths. Section 35 deals with the appointment of the Chief Coroner and Deputy Chief coroner. Section 42 empowers the Lord Chancellor to provide guidance to the Senior Coroner on the operation of the coroner system. Regulation making powers of the Lord Chancellor under Section 43. Coroners (Investigation) Regulations 2013.?

PART TWO: Partial defences to murder - 2004 report by the Law Commission for England and Wales. The partial defences are diminished responsibility and loss of control. Section 59 assists or encourages suicide. Section 62 possession of images of children which is pornographic, obscene or offensive in nature. Section 73 offences sedition, seditious libel, defamatory libel and obscene libel are abolished.?

PART THREE: Criminal evidence, investigations and procedures. Investigation anonymity orders and measures used to protect vulnerable and intimidated witnesses.?

PART FOUR: Sentencing Council and Advisory Panel. Section 120 publishes guidelines for the sentencing of offenders. Section 125 sentencing guidelines are followed by courts in the sentencing process. Section 127 provisions for the extension of disqualifications from driving in certain circumstances.?

PART FIVE: Miscellaneous criminal justice provisions. Domestic, Violence, Crime and Victims Act 2004. European Union Framework Decision 2008/675/JHA treatment in the UK of criminal offences committed elsewhere.?

PART SIX: Legal aid and payments for legal services. Pilot schemes to civil legal aid in localities (Section 149). Damages-based agreement to employment matters (Section 154).?

PART SEVEN: Criminal memoirs. Section 156, Offenders can be ordered to pay back benefits as a result of giving accounts of crimes in the media. Section 163 amount that may be recovered from the offender is limited.?

PART EIGHT: Amendment to the Data Protection Act 1998 powers of the Information Commission. Miscellaneous provisions include orders, regulations, extent and repeals.?

Inquest hearings

Hearing - Inquests are held in a publicly open court. Inquest hearings can last from 30 minutes to weeks - depending on what has happened or what issues were explored.?

Evidence - Factual information that could assist with the coroner's inquiry. Take an oath or affirmation to provide the court with truthful evidence. Evidence to be admitted without the witness being present (Rule 23 Coroner Inquest Rules 2013), read the witness statement in full or the relevant parts.?

Conclusion - The coroner's conclusion will be based on the evidence heard. Interested parties or legal representatives will have the opportunity to address the Coroner on the law and conclusions before the final decision.?

Pre-inquest view hearings

An administrative hearing is typically held where an inquest is complex or involves several interested persons.?

Outlined in Rule 6 Coroners Rules 2013.?

Held if particular issues of law or procedure need to be determined by the Coroner before the final inquest.?

Coroner staff will give evidence about the identity of the deceased and preliminary plans for the final inquest hearing. These include details of witnesses giving evidence, details of the final inquest, the time length, whether a jury will be needed and other hearings needed.?

Essential elements of the pre-inquest hearing are an agenda in advance, the hearing and ruling with reasons.?

• The agenda: the identity of interested persons, the scope of the inquest, Article 2 engagement, jury requirement, provisional list of witnesses, disclosure, jury bundle, and venue for hearings.
• The hearing: It should follow the agenda that is already outlined. Ordinarily, be held in public, Rule 11(3). Rule 11(5) coroner can direct the public to be excluded from the hearing to consider interests of justice or national security.?
• Rulings: A brief ruling should be provided during the hearing. All coroner decisions should be summarised in writing and circulated to interested persons. Ruling on a contested issue should be accompanied by brief reasons justifying the corner's decision.?

Article 2 Inquest and Jury Cases?

As a result of the European Convention on Human Rights, a duty was imposed on the coroners court to consider the rights set out in the ECHR.?

Article 2(2): states must take appropriate steps to safeguard the lives of individuals. Protecting an individual from themselves. The purpose is to help support those in vulnerable positions such as those in custody or with mental disabilities.?

VICTIMS: Individuals who are in custody of, and under the care or guardianship of the State have died. Detained under the Mental Health Act or where they are a prison serving time. Positive obligation on the state to protect an individual, is necessary to show that the State knew or ought to have known of a real and immediate risk to the life of the individual. However, they failed to take whatever action they could in their powers and reasonable to prevent the risk.?

CONCLUSIONS: Investigating coroner can issue a Regulation 28 Report. Outlines failings and actions to be taken to remedy. Prevent future deaths from occurring in similar circumstances to those that gave rise to the Article 2 inquest occurring. It provides the coroner court with a bigger remit and extra scope to investigate circumstances where an individual has relied on protection from the state.?

Prevention of Future Death Reports?

If during an investigation, a coroner becomes concerned about circumstances that create a risk of future deaths the coroner must make a report to the person or organisation that the coroner believes should take preventative action.?

Paragraph 7 Schedule 5 Coroners and Justice Act 2009 - provides coroners with the duty to make reports to a person, organisation, local authority or government department. The coroner believes that actions should be taken to prevent future deaths.?

All reports and responses must be sent to the Chief Coroner. Regulations 28 and 29 Coroner Regulations 2013 sets out procedures that apply to reports and responses.?

Chief Coroner considers the following factors:

• Need for open justice?
• Importance of information to the public interest
• Harm may be caused by the publication of the information?

Lee Brown: Prevention of future death report?

12th April 2011 - 8pm Bur Dubai Police Station in Dubai, UAE?

25th July 2015 - investigation into the death of Lee Bradley Brown?

4th November 2022 - end of jury inquest

Factors contributed to Lee's death:?

• Beating received from other detainees and police officers?
• Lack of adequate food and water?
• Lack of habitable living conditions
• Lack of access to necessary medical care
• Lack of access to consular services
• Inadequate clothing provided for conditions stayed in?

Coroner Concerns: Risk that future deaths could occur unless action is taken.?

1. No emergency access protocol to ensure consular officers can reach detained British nationals in a reported emergency.?
2. Current FCDO travel advice. Insufficient information relating to the consequences of detention in Dubai. Inquest heard that new cases reporting allegations of torture or mistreatment have risen.?
3. Gain consular access to detained British nationals who may be suffering from a mental health crisis.?

Raneem Oudeh and Khaola Saleem: Prevention of future death report?

Legal Powers:

Paragraph 7 Schedule 5 Coroners and Justice Act 2009

Regulations 28 and 29 Coroners Regulations 2013

Investigation and Inquest:

2014 - Raneem Oudeh came to the UK to be with her mother Khaola Saleem who had two other daughters.

April 2018 - Revealed to her family she was subject to domestic abuse, and coercive and controlling behaviour. Contacting West Midlands Police on a number of occasions.?

2 April 2018 - Raneem Oudeh called 999 reporting the partner's threats. Police attended but no effective investigation was undertaken.?

27 April 2018 - Raneem Oudeh called an ambulance as she suffered from chest pains. She revealed her husband was volatile and violent towards her causing severe bruising. A nurse from the hospital called 999 to report that Raneem was a victim of domestic violence. Police attended but no investigation was undertaken.?

27 May 2018 - Raneem called 999 in a distressed state. Police attended but no further investigation. Further calls made on 4 occasions implicating incidents of domestic abuse.?

16 August 2018 - Raneem obtained a non molestation order.?

26 August 2018 - Raneem and Khaola attended the Rotana Shisha Lounge in Birmingham. He slapped Khaola. The police were called but their response was delayed by a firearms incident.?

At just after midnight he had murdered Raneem and Khaola outside their home address. He was convicted of both murders.??

30 August 2018 - death of Raneem Oudeh and Khaola Salem?

31 October 2020 - investigations into the inquest before a jury

Evidence = risk of future fatalities to a vulnerable group.?

Coroners Concerns:

• Evidence that the domestic abuse team within the Public Protection Unit were seriously short-staffed.?
• Inquest was told cases are not being investigated due to lack of resources in the department.?
• Repeat victim of domestic violence, controlling and coercive control from a man who made threats to kill her. Serious risk due to a lack of effective investigation by the department responsible for investigating domestic abuse.?

Conclusion of hearings

• Accident
• Misadventure
• Alcohol or drug-related
• Industrial disease
• Killing = lawful or unlawful
• Natural causes
• Open
• Stillbirth
• Suicide
• Road traffic collision

Important terminology:

Article 2 Inquest - Someone has died under the care of the state (prison, police custody or sectioned). The state must take appropriate steps to safeguard the lives of people who are in its care. How did the deceased die? By what means? In which circumstances??

Balance of probabilities - Coroner or jury concluding they must decide upon this term. It is more likely than not that the event occurred or that someone died in a particular way.?

Beyond a reasonable doubt - The coroner or jury is concluding an unlawful killing. Sure based on the facts of the case there are no other logical events.?

Coroner - an official who holds the inquest and orders the post-mortem examination.?

Coroner’s officer - helps the coroner with the inquest process. Corresponding with interested persons. Managing the disclosure of information.?

Inquest - A judicial inquiry held when there has been a sudden, unexplained, violent or unnatural death. The purpose is to determine how, where and when the death occurred.?

Jamieson Inquest - Article 2 is not engaged in this inquest. The coroner will deal with the four questions to answer: who the deceased was, where they died, when they died, and how they died.?

Middleton Inquest: Article 2 inquest?

Narrative conclusion - Short-form conclusions, suicide or natural causes. The coroner or jury will outline the circumstances of the death in a short description. The questionnaire is produced for the jury to answer and reach a conclusion.?

Open conclusion - No conclusion can be reached based on the evidence presented.?

Post mortem - Detailed examination of the body to determine the cause of death. Also known as an autopsy.?

Prevention of Future Deaths Report - The Coroner becomes aware of something during the investigation which suggests other people are at risk of dying if changes are not made. Duty to write to the appropriate authority, person, or organisation who has the power to make a change. Regulation 28 Report.?

Rule 23 - The Coroner may decide that a witness's written statement can be read aloud in court. Witnesses do not have to attend in person to answer questions.?

Short form conclusion - Suicide, industrial disease, misadventure, and natural causes.

Until the next Legal Thought,

Elicia Maxwell