Welcome to ‘Did You Know?’, Hempsons’ publication designed to keep you informed about the latest legal developments, legislation, and noteworthy case law across our sectors.

This edition is a spotlight on inquests, and includes insights on short form conclusions, PFD reports, expert witness testimonies, and more.

In future editions, we will explore topics such as employment, mental health, the Court of Protection, and more, ensuring you stay well-informed about the latest developments in these areas.

We hope you find the articles in this edition both interesting and useful. If you need any legal assistance, have questions, or wish to discuss any of the issues covered, we would be delighted to hear from you.

In January 2025, the long-awaited Chief Coroner’s Guidance for Coroners on the Bench was published. It is detailed and comprehensive guidance which incorporates a large number (but not all) of the previously published Guidance Notes and introduces some subtle changes.

Prior to January 2025, Coroners were assisted by Guidance No.17 “Conclusions: Short Form and Narrative”, which aimed to achieve greater consistency across England and Wales in the use of short-form and narrative conclusions.

One available short-form conclusion was “Misadventure”, described as “when a death arises from some deliberate human act which unexpectedly and unintentionally goes wrong.”

The new guidance introduces a subtle but important change; paragraph 46 elaborates that “Medical Misadventure” might be the conclusion “when a recognised complication of an elective surgical procedure has come about with fatal consequences”. Previously, Coroners often gave a narrative conclusion in such circumstances. The new guidance offers an alternative conclusion, which will likely become more widely used in the future, given that the new guidance repeats the previous emphasis on Coroners reaching a short-form conclusion “wherever possible as this has the advantage of being simple, accessible and clear for statistical purposes”.

It will be interesting to see what emerges once statistics are collated from deaths resulting from “Medical Misadventure”.

Regulation 28 of the Coroners (Investigations) Regulations 2013 imposes a duty on Coroners to issue a Prevention of Future Deaths (PFD) report if they identify an ongoing risk that could lead to another death. The report should be issued to the person/organisation with the power to implement the necessary changes.

It is common for organisations to feel they have already provided sufficient evidence that any ongoing risk has already been addressed and a PFD report is unjustified. Occasionally, an organisation can be issued with a PFD report raising matters outside their remit. It is often assumed that, in these situations, we can write to the Coroner to ask for the report to be amended or withdrawn. However, Coroners do not have any power to withdraw or amend a PFD report once issued, even if they accept that it is inaccurate or directed to the wrong recipient.

If you receive an inaccurate PFD report or it is sent to you in error, you should respond in writing within 56 days (unless a longer period has been granted) setting out the reasons why the report should not have been issued and/or why further action is not required. It is likely that this response will be published on the Judiciary website alongside the PFD report. It is important to reply even if you dispute the contents of the PFD report, as the Chief Coroner has recently begun publishing the names of organisations who fail to respond, which could result in negative publicity.

It is the duty of a professional witness attending an inquest to provide information that assists the Coroner and jury (if applicable) in understanding the circumstances surrounding the death of the deceased. Evidence given should be based on facts and the witness’s personal understanding. A professional witness could be any individual who was involved in the care or treatment of the deceased, or they could be an external expert witness who is invited to offer their professional opinion or advice on specific matters.

The offence of contempt of court is a strict liability offence, meaning that intention is not a factor taken into consideration when assessing guilt, and is subject to criminal sanctions. A person is guilty of contempt of court if they interfere with, obstruct, impede or prejudice the administration of justice. Although this is a broad definition, a Coroner only has jurisdiction to deal with matters of ‘contempt in the face of the court’, which covers anything that occurs inside of court. This could include being disruptive, using offensive language or failing to comply with court orders.

Typically, witnesses in Coronial proceedings are required to provide evidence based only on facts rather than opinion. Despite this, the opinions of professional witnesses can be helpful for the Coroner to establish the answers to important questions, and weight can be placed on these where necessary, particularly where they concern matters in dispute.

In the recent judgment of R (Bailey) v Secretary of State for Justice [2023] EWHC 821, the High Court ruled that it was unlawful to amend the Parole Board rules to prevent prison staff from providing their opinion on whether a prisoner was suitable for release when giving evidence to the Parole Board. This then led to discussions around whether the failure of staff to provide their view on the “ultimate question” (whether a prisoner should be released) when asked orally during a court hearing or tribunal would amount to contempt of court.

In summary, the Court determined that: “in a court or tribunal to which the law of contempt applies, refusal to answer a relevant and necessary question put by the tribunal constitutes a contempt in the face of the court”.

This suggests that, should a professional witness at an inquest be asked a ‘relevant and necessary question’ whilst giving evidence, even if this is a question of opinion, they would be expected to answer should it ‘serve a useful purpose’. This is particularly significant when considering questions of opinion that assist the Coroner directly with answering the “ultimate question”, which in this context would be the four statutory questions of who died, when they died, where they died, and how they came by their death.

Despite this, the Court isn’t required to take action if contempt occurs and there are other more common routes to dealing with non-compliance of witnesses, such as reporting an registered medical professional to their regulatory body for failing to assist in a public enquiry. Nonetheless, legal professionals and witnesses should be aware of the risks when it comes to objecting to questions of opinion without good reason (of which there may be many).

Artificial Intelligence (AI) is increasingly being used in the UK justice system, including the coroner’s court. The aim of using AI in the court system is to improve efficiency, increase accuracy, and to provide a streamlined service where possible. Coroner’s courts are different compared to other courts,  it is not an arena to attribute blame but rather to seek the truth behind someone’s death, and any subsequent findings can be used to improve learning from those deaths.  AI is being used in two ways: the tracking of pertinent information, and digital autopsies. The tension in a coronial investigation is not new for a bereaved family and balancing it with family dignity remains a challenge for all those involved in the investigation.

In R v Khan (1990), it demonstrated the balancing act the Coroner has when preserving the bereaved and the family’s dignity in the pursuit of justice: the court had faced an emotional plea from the grieving Muslim family not to exhume the daughter’s body. This is particularly crucial in Islam as the sanctity of the body after death is critical. Nevertheless, the court prioritised the need for forensic evidence, and the exhumation took place. This matter raised questions about how evidence is gathered, the limitations of the court’s powers, and how the justice system balances upholding religious and cultural values – Article 9 [HRA 1998] and finding the truth – Article 2 [HRA 1998].

The tensions between finding the truth and balancing it with family dignity remain as relevant today. In the matter of Noah Donohoe (2024), Noah went missing after he went to meet his friends and was found deceased 6 days later. The Police Service in Northern Ireland (PSNI) had employed AI software to examine CCTV footage in the tracking of information of whether he left his home in the days before he went missing. However, there were cost implications and delays as the trial period of the AI software had expired without notification and had to be subsequently purchased by PNSI for its use ahead of the inquest.

AI is progressively being used in digital autopsies, where CT and MRI scans can create 3D images of the deceased and provide insights to the cause of death more readily, rather than an invasive examination taking place. This technological shift can speak directly to the concerns raised in many cases, whereby AI can preserve any cultural and religious beliefs about burials and to preserve the physical integrity of the body. If AI does miss critical medical findings or if something subtle is overlooked, including issues with the software itself, there is a potential risk to be found within the Coronial findings.

Overall, it may be a wise suggestion to not wholly rely upon AI, but to use it as a tool instead: assisting pathologists in their work and the Coroner in reaching an appropriate conclusion.

The purpose of an inquest is to determine the medical cause of death and answer 4 questions: who died, when they died, where they died, and how they came to their death.

Typically, the first 3 questions are very easy to answer and the focus of an inquest will be on the 4^th, that of how they came to their death. However, there may be cases where the question of “who” died isn’t certain. To answer this question, the Coroner needs to determine the name they were known by at their death.

While most people will simply use and be known by the name they are given at birth, which is recorded on their birth certificate, this isn’t always the case, and some people may adopt a different name. In fact, there is no such thing as a “legal” name in English law – a person aged over 16 may choose to adopt a new name at any time in their life for any reason, they have a right to choose their own name, and their name is what they’re known by and not the name set out in any legal document. Legal documents (e.g. a deed poll or marriage certificate) can provide evidence of what a person has chosen their name to be, but they don’t create a “legal” name – as one doesn’t exist.

The latest version of the Coroner’s Bench Book (guidance published for Coroners on Inquests by the Chief Coroner) has been updated to include guidance on answering the question of “who” died where the deceased was transgender. Gender transition does not create a new “legal” name, as there is no such thing as a “legal” name – even where the deceased has been granted a Gender Recognition Certificate under the Gender Recognition Certificate Act 2004. It is for the Coroner to determine the name that they were known by at their death, based on the evidence. A Gender Recognition Certificate can of course be used as evidence of what that person chose to be their name, but there isn’t any requirement for the Coroner to use this name if there is evidence that the person was known by a different name at their death.

Disputes may arise where the bereaved wish for the Coroner to register the death using the name given to the deceased at birth. The Bench Book notes that while Coroners are permitted to record an earlier name (“formerly known as”) on the Record of Inquest, there is no requirement to do so – not only may this be disrespectful to the deceased’s wishes, it may in fact may be a criminal offence, where a person has been granted a Gender Recognition Certificate.

Under s.22 of the GRC Act, it is a criminal offence for a person in public office (including Coroners) to disclose that a person has applied for and been granted a GRC. Coroners may accordingly risk committing a criminal offence if they “deadname” the deceased and disclose their trans status.

The case of R (Robinson) v. HM Assistant Coroner Blackpool & Fylde is a judicial review case arising from a jury inquest into the death of Mr Robinson. On 11 March 2021, Mr Robinson was stopped by police on suspicion of driving a stolen vehicle. When Mr Robinson exited the vehicle, he was restrained by officers, during which time it appeared he had placed something in his mouth and was attempting to swallow it. The officers suspected he was trying to swallow drugs.

The officers placed Mr Robinson in handcuffs on the ground and attempted to get him to spit out the object, but Mr Robinson became unresponsive. Police commenced CPR and called for ambulance assistance. Officers did not suspect that Mr Robinson’s airway was obstructed, but Mr Robinson went into cardiac arrest. Paramedics attended and initially thought that the officers had conducted an airway check and it was only in the ambulance that a paramedic noted a blockage to Mr Robinson’s airway and removed the package using forceps. Advanced life support and CPR continued in the ambulance, but Mr Robinson was pronounced dead on arrival to the hospital.

The Inquest

The Coroner determined that Article 2 was not engaged, and a rider of neglect was not left to the jury. There was not sufficient evidence that the use of force was either unreasonable or disproportionate, that there was a breach of a duty of care, or that the risk of death was a reasonably foreseeable consequence of any misconduct, and Article 2 was not automatically trigged by the circumstances.

Following his summing up and legal direction, the Coroner left misadventure or a short factual narrative as the only conclusions available to the jury. He did not issue a Regulation 28 (Prevention of Future Deaths) report.

Judicial Review

The family of Mr Robinson challenged the Coroner’s decision by way of judicial review. They argued:

• that Article 2 ECHR was engaged
• the Coroner’s summing up was inadequate
• the Coroner was required to have issued a PFD Report.

The Court dismissed all three grounds of challenge.

In respect of the first ground, Kerr J emphasised that misadventure cases are often unpredictable and not necessarily due to state fault, and thus do not justify automatic Article 2 application.

The Court found that the Coroner’s directions and summing up could have been clearer but there was no legal error, and the jury understood the directions.

The short form conclusion of misadventure clearly pointed to the jury’s view that the officers were not significantly to blame for Mr Robinson’s death.

Why is this significant? It demonstrates that the jurisprudence of Article 2 continues to develop and that the categories of Article 2 cases is not closed. There are some deaths that occur in the custody of the state where Article 2 will continue to be automatic, death by suicide in state custody is an example. What this case however demonstrates is that because of the unpredictability of death by misadventure and the absence of blame, even in police custody, there is no extension of those classes of automatic engagement of Article 2 simply as a consequence of the deceased “being in custody”. We will wait and see how Article 2 continues to develop.

Historically, in the 19^th century, various Coroners recorded the conclusion of deaths as “sudden fright” or a “visitation by God”, and this was largely due to individuals dying for unknown reasons, whether it was from a sudden intense emotional reactions to events or having an unexpected encounter, and the following this, the Coroner would therefore attribute their deaths to be from supernatural causes.

Of course we don’t expect to see the modern day Coroner to record such conclusions in the 21st century, because “fright” alone is considered as an insufficient medical explanation. The progression and development of medicine has led to further investigations of sudden deaths, some of which now can be attributed to various causes such as cardiac arrests, stress induced arrhythmias or takotsubo cardiomyopathy. Notably, inquests did not used to assign blame to any particular person, particularly if they caused the fright, but the fright itself was considered a real and fatal factor which led to their death. This legal position has now shifted to even if the fright indirectly caused the death, such as being burgled, the law would now hold the frightener to be legally accountable with manslaughter charges (i.e. the fright was caused by the burglar which then led to the burgled suffering a cardiac arrest).

There are historical cases where the fright has been linked to not a living person, but to ghosts. In the Hammersmith Ghost case (1803), two women were so frightened by an alleged ghost that they died from shock a few days later. Notably, there were local reports suggesting the “ghost” was a prank made by a man disguised in a white burial shroud. Others believed it was a person who died from suicide that was buried. This fear carried on for a few weeks and led to a mistaken killing by Francis Smith, a citizen who was concerned about these reports and took action. His action, however, led to him shooting a bricklayer, Thomas Millwood, who was simply wearing white work clothes. Francis Smith was tried and found guilty of murder despite his honest belief that it was a ghost, and though later down the line, he received a royal pardon and his sentence was limited to one year hard labour, it highlighted the limitations in criminal law using a “mistake of fact” as a defence.

Similarly, Jane Lees (1885), a nine-year-old girl had reported the fear of ghosts and six hours before her death stated, “the ghost is coming”. HM Coroner Sam Brighouse noted her distress and that the fright had indeed contributed to her death.

In summary, Coroners’ conclusions may no longer reflect the fear itself from “fright” or the feeling being from “ghosts”, but the impact that fear can have on a person, better understood in both psychological and physical terms, is still considered by Coroners.

Hempsons lawyers regularly appear at inquests across the country. Our team assists NHS clients, individual doctors, dentists, and other healthcare professionals in preparing for inquests, providing advice and support to those required to submit a report to the Coroner, give evidence as a witness, or participate as an “Interested Person”. Our extensive experience in handling high-profile inquests allows us to guide clients through delicate and emotional proceedings, ensuring their interests are protected. We also advise on responding to ‘Prevention of Future Deaths’ letters and provide representation to ensure the inquest is conducted properly and concluded effectively.

Contact us today for expert advice and support.