February 5, 2019

Including facts which did not directly cause the death on the Record of Inquest

R (Paul Worthington) v HM Senior Coroner for Cumbria [2018] EWHC 3386 Admin

The High Court has recently considered what findings are permitted to be included by a coroner in a Record of Inquest. 

The case arose from the high-profile (second) inquest into the death of 13 month-old Poppi Worthington.  The coroner made a finding that the deceased had been sexually assaulted in her father's bed prior to her death. However he found that this assault did not cause her death, which was from asphyxiation due to the position of the bedclothes, or her position within the bed or overlaying, or a combination of all three.  The fact of the sexual assault was included in the Record of Inquest, for the purpose of explaining how Poppi came to be lying in the unsafe sleeping environment.  The coroner explained his findings and reasoning in a lengthy document.

Poppi's father challenged the inclusion of the sexual assault in the Record of Inquest, on the basis that because it was not medically causative of the death, it was not relevant to recording 'how she came by her death'.

The High Court dismissed his challenge and concluded that it was lawful for the coroner to record the sexual assault as it was an integral part of the factual matrix. This formed the immediate circumstances of the death, because it was the reason that Poppi had been moved from her cot into the bed where she died.  The court also re-iterated (at paragraph 43) that one function of an inquest is to seek out and record as many of the facts concerning a death as the public interest requires, and that a coroner is at least entitled to record their finding in relation to a main issue, even if that is to explain why they did not find that it directly caused the death. 

This judgment is likely to be significant for future inquests because:

  • Interested persons are likely to cite this decision as authority for a Record of Inquest to lawfully include details of background circumstances to a death and other findings of fact;
  • Attempts might be made to suggest that the distinction traditionally drawn between Article 2 and non-Article 2 inquests as to the findings in relation to wider circumstances surrounding a death, have become blurred and are now rather meaningless.
  • Coroners might now be more willing to produce more detailed Records of Inquest based on wider circumstances of a death, and their findings in respect of the main issues at inquest.

However, in my view, this decision does not extend the current law and turned very much on the specific facts of the case. It remains the case that only matters relevant to the factual matrix of how the person came by their death (the immediate circumstances) will usually need to be included in the Record of Inquest, except in Article 2 inquests, where the 'wider circumstances' are required too.

If a coroner is being invited to record wider circumstances (in a non-Article 2 inquest) or non-causative findings then this case should be cited, with submissions made regarding its proper interpretation and context.