Chief Coroner – Leeming Lecture 2022

Chief CoronerSpeeches



  1. Thank you for those generous words of introduction. I did not personally know Professor Jennifer Leeming, but I am aware of the great affection and high esteem in which her colleagues and friends held her. It is a privilege to have been invited to deliver this evening’s lecture.
  2. I should like to begin with a quotation:

“But when the crowner sits upon it
Who can dare to fix the guilt?”

So sings the chorus of townsfolk in the Prologue to Benjamin Britten’s celebrated opera, Peter Grimes. The fisherman Peter Grimes has just returned to port with the body of his apprentice, who, he says, died of thirst after a storm blew their boat off course. There is local gossip hinting at foul play. The town’s coroner conducts an immediate inquest and, after hearing sworn evidence from Grimes, returns a verdict – or, as we would say today, a short-form conclusion – of accidental death.

3. The outcome of the inquest may be inevitable, yet it satisfies nobody. Outwardly, the townsfolk appear to accept it:

“When women gossip,” they murmur, “the result
Is someone doesn’t sleep at night,
But when the crowner” (or coroner) “sits upon it,
Who can dare to fix the guilt?”

But Peter Grimes knows what they are really thinking. He protests:

“The case goes on in people’s minds
The charges that no court has made
Will be shouted at my head.”

4. Let’s use the prologue from Peter Grimes to draw some wider lessons about the conduct of coroners’ inquests. Of course, we have to be careful. The episode is, obviously, a fictional one. And no one, I hope, would suggest that we should sing our way through inquests. But as we shall see, Britten’s operatic inquest in many important respects closely replicates actual practice at the time of its setting. and, indeed, more recently.

5. What do we notice about the inquest from Peter Grimes? First, it is very short and takes place immediately after the death upon which it touches. It is conducted in front of all the townsfolk. The coroner does all the questioning. There are no lawyers. The inquest produces a clear verdict that is the right conclusion on the available evidence. We may also note that the coroner does not attempt to arbitrate between the competing points of view of Peter Grimes and his fellow townspeople or seek to establish which of them is objectively in the right. In short, it is very much the coroner’s inquest – hence the title of this talk.

6. We don’t speak about ‘the judge’s trial’. Why do we feel that it is natural to speak of ‘the coroner’s inquest’; and does the answer to that question tell us something about how an inquest is designed to support the quest for objective truth?

7. Now, some may find it surprising that I have chosen a topic as wide and general as the coroner’s inquest, but I can think of three good reasons why I should do so. First, a lecture of this kind affords an opportunity to reflect more deeply on principles that we perhaps take for granted and to articulate the underlying philosophy in a little more depth than usual. Second, we happen to be going through a time of rapid change in this area, with many possible legislative reforms on the horizon, and we cannot properly assess the impact of those events without, as it were, going back to basics. Third and last, it may be helpful for me, still comparatively new in the office of Chief Coroner, to set out in public some of the general ideas that I have been trying to articulate in speeches and talks that I have given in more private settings.

8. I suppose the first thing to do is to point out that my topic is not quite as wide as it might at first sight appear. The inquest is, after all, only part of the investigation carried out by a coroner. Indeed, most deaths that are reported to coroners do not result in an inquest at all. Sometimes, there may not even need to be an investigation. Where the coroner does decide to investigate, it often happens that a post-mortem examination suffices to give a cause of death and allow the death to be registered.

9. So in this lecture, I will deliberately confine myself to the inquest proper, that’s to say the hearing – which may or may not involve a jury – that a coroner conducts in certain cases.

10. The coroner’s court is an inferior court of record. Historically, its purpose has been to dispense a form of summary justice rather than to resolve all the surrounding issues to which a death may happen to give rise. To this day, coroners are subject to an express statutory duty to conduct a coroner’s investigation “as soon as practicable”. The parameters of the investigation are those set out in the Coroners and Justice Act 2009, namely to ascertain four things: who the deceased was, and how, when and where the deceased came by his or her death. Neither the coroner nor the jury (if there is one) may express an opinion on any matter other than those questions or the particulars to be registered concerning the death. Nor may their determination of the four matters to be ascertained be framed in such a way as to appear to determine any question of criminal liability on the part of a named person or civil liability. And Rule 19(2) of the Coroners (Inquests) Rules provides that a coroner must disallow any question put to a witness which the coroner considers irrelevant.

11. The Court of Appeal has made it clear that even in an Article 2 case, where the question how the deceased met his or her death embraces the wider circumstances of the death, it is not incumbent on the coroner to investigate, still less state conclusions, in relation to every issue raised, but only those issues that are at least arguably central to the cause of death[1].

12. Until well into the last century, there was little change in this traditional ‘summary’ approach. A minute or two ago, I said we would see that the fictional inquest in Peter Grimes was not so very far from the truth. Let me give an example. If you take the A483 road from Welshpool to Newtown in mid-Wales, you will pass a small side road on the left that leads to the remote village of Abermule, the scene of a fatal train crash early in the last century.

13. It was the failure of a supposedly fool-proof safety system that led to the collision, which took place on the single line section between Newtown and Abermule. The Aberystwyth to Manchester express collided head-on with a local train travelling from Whitchurch to Aberystwyth. The crew of the express were in possession of the unique safety token that entitled their train to occupy that stretch of track. As a result of the incompetence of the station staff at Abermule, the crew of the local train were also in possession of a unique token. Had they but checked it, as they were supposed to do, they would have realised that it actually related to a different section of line, the section they had just vacated.

14. Seventeen people were killed and a similar number injured. The collision happened on 26 January 1921. The inquest took place at Newtown. The jury, which concluded that the stationmaster and signalman at Abermule had been guilty of “great negligence warranting the most severe censure”, returned its verdict on 3 February, just eight days after the disaster.

15. There are all sorts of reasons why we cannot achieve that degree of expedition today. In the last hundred years, it is trite (but true) to say that life has become much more complex in many ways, not least – to take an example from the railways – through the advent of sophisticated control systems, first electrical, then digital, a development that has been matched by increased quantities and ever more technologically advanced forms of primary evidential material (such as photography, video footage and other forms of digital data). We are a long way from a few eyewitness statements and ‘the wrong safety token’.

16. Attitudes towards the involvement of families in the aftermath of death have also changed for the better, particularly since the Marchioness tragedy and other major disasters such as Hillsborough. There is a general expectation that getting to the “cause of things” in a technically complex age demands a technically complex explanation This is reflected in the development of specialist investigators like the Rail Accident Investigation Branch (RAIB) where, rightly, specialist knowledge can be concentrated and preserved institutionally over time, enabling our society to become better at explaining the causes of mishaps and thus prevent them from happening again.

17. As with the rest of society, during the years that have passed since the Abermule rail crash, coronial proceedings have become steadily more and more complicated. That process has exposed a persistent tension at the heart of our death investigation system, one that may not be capable of easy resolution. As well as being complex, do we not sometimes find that the coronial process can also be more contentious, more adversarial – more bad-tempered even – than is good for any of those involved, particularly the bereaved? In life, as in Britten’s opera, evidence, even irrefutable evidence, does not always dispel suspicion or gain universal acceptance.

18. It would take another lecture in itself to analyse the historical reasons for these developments. Some may have been avoidable. Others, as we have seen, are probably an inevitable consequence of the increasing complexity of modern life. At the same time, however, it’s important to remember that not all inquests are complicated and comparatively few are contentious. What interests me is whether in recent decades we may have lost sight of some basic ideas and principles and, if so, whether there is anything we can now do about it.

19. What, then, is the essential difference between the coroner’s inquest and other court proceedings in this country? The proceedings in other cases are driven by the participants. They do not belong to the court in the way that an inquest belongs to the coroner. In a criminal case, the prosecution decides whether to institute proceedings, what charges to bring and what evidence to adduce in support. The defendant decides whether to give evidence or call witnesses, and is perfectly entitled to do neither. The judge is a bit like the referee at a boxing match, whose job is to ensure that the rules are followed and – through a jury – to decide the eventual ‘winner’. Similarly, in civil proceedings, it is the claimant, not the judge, who decides whether to make a claim and, if so, against whom and on what grounds. This is a point that is often not well understood by non-specialists (and even by some lawyers). It is easier to grasp in civil litigation, but it is sometimes obscured in modern criminal proceedings. Certainly in the minds of the public, the prosecution, the police, the prisons and other forms of ‘officialdom’, including the judicial system, are often incorrectly blurred into one.

20. By contrast, Jervis on Coroners reminds us that the aim of the inquest is to find out the objective truth, the “true facts”, in the public interest, and not the limited “truth” as between and for the purposes of two or more parties. The coroner’s inquest is the culmination of an investigative process, not a dispute. The coroner has a wide discretion as to the form of the inquiry, which is never a trial between combatants. This is why the Coroners (Inquests) Rules specifically prohibit an ‘address to the facts’ by an interested person. The role of the interested person is to participate by asking questions to elucidate the truth. ‘Addressing the facts’ is what advocates do in criminal cases. They say to the jury: “this is our case as to what happened”, and they try to persuade the jury of that version of events. But the job of the interested person is not to ‘persuade’ the coroner. Instead, the wider community (represented, in a sense, by the concept of the interested person) comes together to assist the coroner in finding out the truth. Ultimately, it is the coroner who must ascertain what happened, rather than deciding which interested person is the most persuasive.

21. There is something else about an inquest which, in my opinion, is not spoken about sufficiently often. It is something we should be shouting from the rooftops. The inquisitorial nature of an inquest is what guarantees the bereaved family a central place in the process as interested persons. They have rights of participation set down in statute which they simply do not have in a criminal trial or in an investigation by a state body such as the Health and Safety Executive, an Accident Investigation Branch, a Service Inquiry or a disciplinary hearing by a professional regulator. I do not mean to suggest that those bodies or proceedings ignore bereaved people. Far from it. Each of these sometimes overlapping forms of inquiry may take place after a death – but it is the inquest (along with its rarer sibling, the public inquiry) which has the participation of the bereaved right at its statutory core.  

22. I have more than once been upbraided for asserting that there are no parties to an inquest and for claiming that inquests are not adversarial. But I am not alone in saying these things. Many of you will be familiar with the classic statement by Lord Lane in 1982, when he was Lord Chief Justice:

“It should not be forgotten that an inquest is a fact-finding exercise and not a method of apportioning guilt. The procedure and rules of evidence which are suitable for one are unsuitable for the other. In an inquest it should never be forgotten that there are no parties, there is no indictment, there is no prosecution, there is no defence, there is no trial, simply an attempt to establish facts. It is an inquisitorial process, a process of investigation quite unlike a criminal trial where the prosecutor accuses and the accused defends, the judge holding the balance or the reins, whichever metaphor one chooses to use.”

23. Where does the persistent confusion about the true nature of a coroner’s inquest come from? I think there are two problems. One is the widespread and incorrect perception that many inquests are inherently controversial. Most people gain their impressions of how coroners’ courts work from what they see and hear reported in the news media. The media thrive on cases having features which – for whatever reason – arouse public interest, and as a result they tend only to cover the minority of inquests that do, in fact, involve an element of controversy. In that minority of cases, a heavy obligation lies on coroners and lawyers practising coronial law to manage the expectations of those involved from the very outset of the process.

24. However, let’s remember that there are approximately 30,000 inquests each year. The vast majority are not contentious but are modest, efficient hearings directed at answering questions expeditiously. In many cases they may last less than an hour, even in as traumatic a death as a suicide – something that is routinely and in my view incorrectly and unfairly characterised in the press as a self-evident indication of deficiency. But to sit and observe such proceedings (as I have done and would encourage everyone to do) is to see a sensitive and proportionate form of justice at a truly human scale.

25. Another problem is that we are not always as precise as we might be in our use of language. People who say that inquests – or, at any rate, some inquests – are “adversarial” are clearly not using that word in its strict legal sense. They are using it colloquially to mean “contentious” or “tense”. To that extent, they may have a point, although it bears repeating that most inquests are not, in fact, at all contentious or indeed particularly tense.

26. But in the context of inquest law and procedure, the word “adversarial” carries a distinct, quite different meaning. It refers to the distinction we have just been discussing, between court proceedings in other legal jurisdictions, where the process is an explicitly adversarial one, and the coroner’s inquest, which is just as explicitly inquisitorial.

27. For those inquests that may be said to have a contentious aspect, it is perfectly true that, for some of the participants, the experience of giving evidence in open court may be one they find daunting. This, of course, can be true of all court proceedings and is something that should be reduced to the minimum. Coroners should make the rules of behaviour in their court abundantly clear. They should control the proceedings so as to keep questioning relevant and within proper boundaries and to ensure that everyone is treated fairly and with consideration. Lawyers, too, have an important part to play. They should familiarise themselves with the excellent new Toolkit[2] issued by the legal regulators. Coroners can, if necessary, take over the questioning of witnesses from an interested person to make sure it stays on track. Witnesses should be reassured that the coroner cannot make them incriminate themselves and that the law forbids the coroner from appearing to determine civil liability or criminal liability on the part of a named person.

28. The desirability of open inquest proceedings is surely axiomatic. I know that sometimes other considerations are given weight, and I do not dismiss them, but I have yet to hear a convincing argument that because, in a minority of cases, the disinfectant effect of sunlight can occasionally prove uncomfortable for certain participants, we should routinely return to the shadows. Surely this is something we ought to have learned from the major disaster inquests and public inquires in recent decades – in particular the second set of Hillsborough inquests? The evidence may be something the bereaved family and the wider public really need to hear. Their loved one may have been seriously let down by an organisation that was supposed to look after them. Or, in another case, it may turn out that everything possible was done to save their family member, and suspicions can be put to rest and doubts allayed. In either situation, it may well be the bereaved family members who, as a result of being able to participate fully as interested persons, ask the crucial question that finally triggers the explanation of their loved one’s death after months or years of doubt and uncertainty.

29. So the coroner’s inquest is not a trial. It follows that there is no “cross-examination”. How can there be, when there are no parties and hence no examination in chief? There is simply examination by the coroner and by interested persons. The interested person’s right to question witnesses comes from Rule 19(1) of the Coroners (Inquests) Rules, which provides that the coroner must allow any interested person who so requests to “examine” any witness. So here again, we encounter confusion arising from the imprecise use of terminology. Even the High Court has been known to slip into this particular error from time to time[3].

30. Let me give another example. I have complained in the past about the way in which coroners have found themselves obliged to adopt the alien vocabulary of other jurisdictions, often in ways that are not as helpful as they might be. Why, for example, do we have to speak about a standard of proof when there is no burden of proof? Would it not be better to speak, write and think of the “level of certainty” or “degree of confidence”?

31. Here again, there is some judicial support for such an approach. In her judgment in the recent case of Maughan[4], Lady Arden used the expression “degree of conclusivity” as a synonym for “standard of proof”. That is partly why the latest version of Law Sheet 1, on Unlawful Killing, prefers to use the word “establish” instead of “prove”, and the new guidance note 17, on Conclusions, puts the so-called standard of proof in this way: “The level of certainty required when reaching conclusions at an inquest (whether those conclusions are short-form or narrative) is the same as the civil standard of proof, namely the balance of probabilities”.

32. Now, it may seem rather pedantic to insist on getting such matters as terminology and vocabulary right, but as St John Henry Newman pointed out more than a hundred years ago, language and thought are inseparable. The way we speak governs the way we think. As I see it, disciplined thought is really just the drawing of proper distinctions. The finer the distinctions we can draw, the more accurate our thought can become. But the inseparability of thought and language means that our ability to think accurately is necessarily limited by our vocabulary. That is why I am firmly convinced that insisting upon the right legal terminology is essential to the preservation of our uniquely inquisitorial jurisdiction.

33. And this takes me to the heart of the question that underlies much of what I want to say this evening. It is all very well my talking about the precise use of terminology but, as we have seen from the different meanings of the word “adversarial”, our vocabulary can sometimes prove ambiguous. Such ambiguities are open to exploitation by those who would undermine the inquisitorial nature of the coroner’s inquest.

34. We are under constant pressure – not always very subtle – to  assimilate assumptions, principles, terminology and practices that originate in other, adversarial jurisdictions. My predecessors repeatedly emphasised that the deceased, and by extension the bereaved, should be at the very heart of the coronial process, and I fully endorse that principle. But, as I said a few minutes ago, it is precisely the inquisitorial nature of a coroner’s investigation that guarantees the centrality of the bereaved. The moment coroners yield their control as investigators to those who would, consciously or unconsciously, convert coronial proceedings into yet another form of adversarial litigation, we run the risk of diverting our attention away from the bereaved to what may sometimes be an extraneous dispute.

35. In making these observations, I am not advocating a return to some mythical golden age when inquests were commonly held in public houses (something that the Victorians decided was a bad idea and prohibited in 1889), or when newly elected coroners paraded before the admiring populace amid the most lavish celebrations, as we know happened at Stafford in 1826, when John Dent was elected county coroner. At the risk of undermining my contention that there was never a golden age for coroners, I can’t resist digressing to remind you that on that occasion, the newly elected coroner John Dent was carried aloft in a chair festooned with evergreens, flowers and ribbons, behind a band of musicians, with a magnificent display of banners at the head of the procession. On returning later that day to his home town of Hanley, this time in an open chariot drawn by eight horses, he was greeted by no fewer than 40,000 members of the public. Dinners were held in his honour throughout the county, even as far away as Wolverhampton. A cow was purchased by subscription, cut into joints and roasted at the various inns around the marketplace in Hanley, and free tickets were distributed to 600 poor people so that they, too, could join in the celebrations.

36. To return to the point I was making before I allowed myself to be diverted by early nineteenth century jollifications in Stoke-on-Trent, there probably never was a time when the coroner’s inquest was invariably non-contentious. Coroners’ proceedings have always aroused intense public interest and, at times, controversy. When John Dent was elected county coroner for Staffordshire two hundred years ago, more than 8,000 freeholders took part in the election. This, remember, was long before the universal franchise. Coroners were seen by many in those days as the champions of the people, because it was often only through their investigations that abuse of power and disreputable conduct by public authorities, for example in connection with prison deaths, could be exposed to the public gaze. Coroners’ juries were used to asking their own questions, and would even call witnesses whom the coroner regarded as unnecessary or irrelevant. Deaths in custody, which some argued should include deaths in workhouses, provide just one example. As the responsibilities of local magistrates included both the management of prisons and workhouses and an ability to restrict the holding of inquests, conflict inevitably arose between the two jurisdictions, and coroners came to be regarded by some as the guardians of the poor.

37. Against that background, it is scarcely surprising that the election of a new county coroner should cause the level of excitement that John Dent’s clearly did. At the same time, there was already debate as to the proper scope of a coronial investigation. Should it be a purely factual medico-legal investigation, or should questions of possible culpability be examined by a popular tribunal?

38. That debate, as we all know, still rages. As I have already made clear, I firmly believe in the inquisitorial ethos of the coroner’s jurisdiction and the centrality of the bereaved that is inseparable from it. It seems to me that if we allow the coroner’s inquest to become a vehicle to enable individuals or groups to ventilate grievances that are more properly resolved through political means or by conventional litigation, we will end up colluding in the marginalisation of bereaved people. Experience in other jurisdictions tells us this kind of process tends to occur incrementally, through gradual procedural changes, each one seemingly innocuous and, on its individual merits, entirely reasonable. But the danger is that step by barely perceptible step, the coroner’s inquest will slowly ossify into a species of trial, with each party stationed behind a barricade attempting to score points, rather than to elucidate. Were such a thing to occur, inquests would become truly uncomfortable places for some witnesses. I do not want that, and I think we should do all we can to avoid it and focus on the joint effort to assist the coroner towards the truth.

39. What can we do to foster a more constructive approach that respects the proper, limited purpose of a modern coroner’s investigation? As I have already mentioned, I think a lot of it is to do with managing people’s expectations. That is something coroners already try to do, but lawyers and advocates, as professionals subject to an overriding duty to the court, have a responsibility not to undermine the coroner’s efforts to manage expectations. They should advise their clients as to the proper purpose and limits of a coroner’s investigation. Most do that, but a minority sometimes give the impression that they are actively cranking up a confrontational atmosphere. I think that’s wrong. They, too, have a duty to manage the expectations of their clients, and to do so responsibly, without seeking to exploit the court’s process to pursue some extraneous agenda.

40. At least in the eighteenth and nineteenth centuries it could be plausibly argued by those who sought to expand the scope of coronial investigations that the coroner’s inquest provided the only available way to expose the fatal wrongdoings of those in authority. Nobody could sensibly argue that today. We now have any number of organisations dedicated to specialist investigations: we have modern police forces, the Health and Safety Executive, the Rail Accident Investigation Branch, the Marine Accident Investigation Branch, the Air Accidents Investigation Branch, the Independent Office for Police Conduct, and many others, all in one way or another subject to the supervisory jurisdiction of the High Court. It is far harder today for official wrongdoing leading to death to pass unnoticed than it was in John Dent’s time.

41. The courts are carefully considering the tendency to try and expand the limits of the inquest beyond those set by the Act[5], that is to say, the four statutory questions. I will mention two recent cases in particular. Because each is now subject to appeal, and in one of them I happened to be a member of the court, I will avoid comment.

42. In Morahan v HM Coroner for West London[6], the Divisional Court rejected an argument that the death of a voluntary psychiatric in-patient from an accidental overdose while on approved leave from hospital engaged the enhanced investigative duty under Article 2 of the European Convention on Human Rights. The court held that the duty did not arise automatically or by reason of any arguable breach of an operational duty owed to the patient by the relevant hospital trust. In a detailed judgment, Lord Justice Popplewell set out some important principles.

43. First, the existence or otherwise of the operational duty is not to be analysed solely by reference to the relationship between the state and the individual, but also by reference to the type of harm of which the individual is foreseeably at real and immediate risk. There may be an operational duty to protect against some hazards but not others.

44. Secondly, the foreseeable risk of the type of harm in question is a necessary condition of the existence of the duty, and is not merely relevant to the question of breach. That is because you cannot decide whether there is an operational duty to take steps to prevent a particular type of harm without identifying a foreseeable risk of the type of harm in question.

45. Thirdly, in cases where vulnerable people are cared for by an institution which exercises some control over them, the question whether an operational duty is owed to protect them from a foreseeable risk of a particular type of harm is informed by whether the nature of the control is linked to the nature of the harm. So a prison’s control over its inmates gives rise to an obligation to protect its detainees against suicide risks because the very fact of incarceration increases such a risk. The same applies to compulsorily detained mental patients, whatever the nature of the mental condition being treated. It also applies to those ‘voluntary’ patients whose residence at the institution in question is not truly voluntary and whose mental condition itself enhances the risk of suicide. In all those examples, the nature of the control exercised by the state is linked to the risk of harm.

46. Finally, an automatic procedural duty can only arise in a category of case if and because all cases in that category necessarily raise a sufficient possibility of state responsibility for the death.

47. The case of Morahan has now gone to the Court of Appeal.

48. The other case is the Court of Appeal’s decision in Maguire[7], which is on its way to  the Supreme Court. The Court of Appeal held that Article 2 was not engaged in relation to the death of a woman who had Down’s syndrome and learning disabilities, and who had been living in a care home pursuant to a standard authorisation granted by her local authority. The mere fact that the deceased was vulnerable and had been deprived of her liberty did not mean that the state’s Article 2 obligations had been triggered. That case, too, concerned the scope of the state’s investigative duty under Article 2.

49. The outcomes of the appeals in Morahan and Maguire remain to be seen, but as the decisions currently stand, both inquests have been found not to engage Article 2 and consequently to be limited to ascertaining “by what means” the deceased died, rather than “in what circumstances”.

50. A further aspect of coronial law that could one day see further development is ‘Galbraith plus’. I raise it in the light of the Supreme Court decision in Maughan. As you all know, ‘Galbraith plus’ is a shorthand expression for the rule that a coroner, in addition to being satisfied that there is sufficient evidence upon which a jury could properly reach a particular conclusion, must also be satisfied that the conclusion is one that it is safe to leave to the jury. Some coroners direct themselves in terms of ‘Galbraith plus’ when sitting without a jury. Personally, that has always seemed to me to be somewhat unnecessary, amounting, in effect, to taking the same decision twice. I understand the need for caution, but my own view is that where there is no jury, while the coroner will naturally consider the safety of any conclusion he or she proposes to make, as well as the sufficiency of the evidence available to support it, the coroner need not expressly articulate a self-direction on both limbs of the ‘Galbraith plus’ test. That’s how I put it in the Wandsworth Borough Council case in a judgment with which both the other members of the court agreed[8].

51. An interesting question is whether ‘Galbraith plus’ has any long-term future at all in the light of Maughan, which as you all know decided that suicide and unlawful killing, like all other short-form conclusions, may now be reached on the balance of probabilities. Not all the reported decisions concerning the ‘Galbraith plus’ rule concern suicide or unlawful killing conclusions but, for reasons that are not difficult to comprehend, the vast majority of them do. As long as the law used to require that a jury be sure of such a conclusion, and not merely satisfied on balance, it made sense that the coroner should not leave it to the jury where, despite the existence of sufficient evidence, the conclusion was not one that could be safely reached. But what does “safe” mean in the context of a situation in which all short form conclusions, including suicide and unlawful killing, may now be reached on the balance of probabilities? Put another way, what is the continuing point of requiring a coroner to be satisfied that a conclusion is one that may be safely reached if the law is content for it to be reached only on the balance of probabilities? This is a problem that existed in legal theory before Maughan, because the Galbraith plus rule was never confined to cases of suicide and unlawful killing, but it seems to me to have become more acute. It will eventually need to be faced up to and resolved.

52. Let me conclude by saying that we cannot afford to take the inquisitorial nature of the coroner’s inquest for granted. I hope you agree that it is something worth defending. If ever we lose it, we will never get it back. Each of us who plays a part in the coroner’s inquest has a responsibility to uphold its unique and priceless ethos. Thank you.

HHJ Thomas Teague QC

[1] R(Allen) v HM Coroner for Inner North London [2009] EWCA Civ 623.

[2] Resources for those practising in the Coroners’ Courts (

[3] R (Lin) v Secretary of State for Transport [2006] EWHC 2575 (Admin).

[4] R (Maughan) v HM Senior Coroner for Oxfordshire [2020] UKSC 46.

[5] [5] The Coroners and Justice Act 2009.

[6]  [2021] EWHC 1603 (Admin).

[7] R. (on the application of Maguire) v HM Senior Coroner for Blackpool and Fylde [2020] EWCA Civ 738.

[8] Wandsworth Borough Council v HM Senior Coroner for Inner West London [2021] EWHC 801 (Admin).