Jonathan Landau successfully acts for Coroner in Judicial Review

23 June 2022

R (on the application of Fatmire Gorani) v HM Coroner for Inner West London and others [2022] EWHC 1593 (QB)

The inquest concerned the suicide of a man suffering from mental illness. Shortly before his death, his family called mental health services for help but the call was not put through to a clinician as it should have been. The following day, he went to his GP who put in place a plan. Sadly, he took his own life six days later.

The main focus of the case was alleged bias on the part of the Coroner towards medical witnesses leading, it was said, to the Coroner inappropriately interrupting witnesses, substituting her own evidence for that of witnesses, putting leading questions and demonstrating a hostile animus to the case being advanced adverse to the medial witnesses. Other grounds including failure to comply with the Article 2 investigative duty (in three respects), irrational findings of fact and failure to hear submissions before making a decision not to issue a regulation 28 report.

The Court roundly dismissed all grounds. The Court was unable to detect any bias and agreed with Jonathan’s submissions that the Coroner’s interventions were appropriate.

Whilst largely fact specific, the judgment includes some points of general interest:

  1. Coroners are obliged to approach an inquest with an open mind, but not with an empty one. They are entitled to form preliminary views on the basis of the evidence they have read and heard, and to test that against the witness evidence before them.
  2. The inquisitorial nature of an inquest is relevant to how questions may be put. There can be no complaint about a coroner seeking to understand a witness’ evidence, summarising it, or testing it to put it in context.
  3. A coroner’s declaration that an inquest will serve to meet the state’s obligation to investigate the death, and that s5(2) of the 2009 Act applies, does not trigger an obligation on the coroner to investigate every aspect of the case to the standards of Article 2. The obligation imposed by s5(2) requires an investigation “where necessary” to ensure compliance with the Convention. The Coroner’s ruling on Article 2 delimits the scope of the Article 2 inquiry.
  4. There is no obligation to hear submissions on the regulation 28 duty. 
  5. It is in circumstances where the Coroner forms the opinion, in the light of the facts revealed by the investigation, that action is required that she is required to make a Regulation 28 report. 

Point 3 is particularly worthy of note. There is a tendency to refer to whether a case is “Article 2” or not, and if it is, then “how” means “how and in what circumstances”. As Garnham J explained, that is not quite the correct approach. The ‘what circumstances’ supplement applies to investigating and making findings of fact on issues that, if not considered, would result in a breach of the Article 2 investigative duty.  It does not open the door to any and every issue.

Click here to view the judgement.



Jonathan Landau

Call 2004

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