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The judicial review centred around the words describing sexual abuse that the Coroner found to have been perpetrated before Poppi’s death, but which had not caused her death. Poppi’s father argued that this detail should be removed from Box 3 in the Coroner’s Record of Inquest. On behalf of the Coroner, Samantha Leek QC argued that the penetration was part of the “wider factual matrix”. The court agreed that the wording was an integral part of the factual matrix which formed the immediate circumstances of the death and the inclusion of that reference in the Record of Inquest was essential to explain why the deceased was in an unsafe sleeping environment which had caused her death. The court gave the following guidance: it would be wrong as a matter of principle for the court to attempt to micromanage inquests by constraining the proper discretion of a coroner to record the answer to the "how" question in light of all their findings of fact. A court should be cautious before seeking to strike out unchallengeable findings of fact which a coroner had carefully considered to be sufficiently important by way of explanation of the means of death to include them within a determination of a s.5(1) question
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