HM Senior Coroner v Alexei

1. LORD JUSTICE SINGH: This is a claim brought under section 13 of the Coroners Act 1988 (" the 1988 Act "). The claim arises from these sad facts which need to be set out briefly for present purposes.

2. On 31 January 2020, the deceased (Richard George Robinson) was found dead at home in a state of decomposition such that he could not be identified. An odontology expert was required to provide a comparison of his dental records. A provisional post mortem report did not establish a cause of death and toxicology samples were also unable to provide the cause of death.

3. On 24 August 2020, an inquest was opened into the death. The final hearing of the inquest was held on 5 November 2020 by Assistant Coroner Catherine Wood. We have seen a transcript of that hearing. As appears from that transcript, it was not possible at that stage for the pathologist, Dr A. G. Nayar, to complete a post mortem report because he was himself off sick.

4. The coroner expressed the view that she was content that on the evidence then before her, the medical cause of death was unascertained. But the coroner also made it clear that, should further evidence become available, then this matter would need to be revisited.

5. We have also seen the coroner's certificate which bears the same date, 5 November 2020, which confirms, in accordance with the conduct of the inquest hearing, that the cause of death was stated to be "unascertained".

6. In due course, the post mortem report was completed by Dr Nayar, which we have seen. This expresses the opinion that death was due to natural causes and gives the causes of death as being 1(a) ischemic heart disease; 1(b) coronary artery atheroma; and 2, right bronchopneumonia chronic obstructive airways disease.

7. As we have said, during the final inquest hearing on 5 November 2020, the assistant coroner indicated that, should further information come to light to assist in identifying the deceased's cause of death, then she would reopen the inquest and apply for a fiat from the Attorney General to make an application for a fresh inquest to be held. In fact, Assistant Coroner Wood is no longer sitting within the London South jurisdiction. Accordingly, the claim has been brought by Senior Coroner Ormond-Walshe in order to ensure the record of the inquest is both complete and accurate.

8. The Solicitor General issued a fiat permitting the application to be made to the court on 5 February 2025. There was an accompanying letter dated 6 February 2025 attaching the grant of a fiat , but making it clear that the granting of the fiat does not provide an indication that this court would order a new inquest and confirming that it is up to the court when served with an application and to make a decision.

9. The claimant then filed Particulars of Claim before this court and prepared a draft consent order which we have seen. It is dated 23 November 2024. The draft consent order has the agreement of the defendant who is the deceased's sister.

10. We are very grateful to Ms Cordone who has appeared before this court to assist the court. The Particulars of Claim helpfully set out both the factual background and the legal framework, which it is only necessary to outline briefly for present purposes.

11. Under section 13(1) (b) of the 1988 Act , an application may be made for another investigation to be held on the basis that it is necessary or desirable in the interests of justice due to the discovery of new facts or evidence.

12. In HM Attorney General v HM Coroner of South Yorkshire (West) & Anr [2012] EWHC 3783 (Admin); [2012] Inq. LR 143 at [10] this court made it clear that although the interests of justice, as they arise in the coronial process, are undefined, it is 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.

13. In the present case the claimant considers that the conclusion containing the record of inquest is incorrect in the light of the evidence which did not form part of the original inquest. It is submitted, therefore, that a fresh inquest is both necessary and desirable in the interests of justice in order to consider the new and relevant evidence, namely the post mortem report and to ensure that the facts are accurately recorded.

14. We accept those submissions and have reached the clear conclusion that, although the agreement of the parties and the fiat of the Solicitor General are not binding on this court, that it would be in the interests of justice for a fresh inquest to be held.

15. Accordingly, we will make an order in the terms of the draft consent order which has been placed before the court, in particular it is ordered that: (1) the record of inquest relating to the death of the deceased is quashed; (2) the claimant shall hold a further investigation into the death of the deceased. Epiq Europe Ltd hereby certify that the above is an accurate and complete record of the proceedings or part thereof. Lower Ground, 46 Chancery Lane, London WC2A 1JE Email: [email protected]