Important new inquest judgment handed down by High Court

March 27, 2024

Nicholas Ostrowski

In R(Bryan) v Coroner for Buckinghamshire [2024] EWHC 26 (Admin), a Divisional Court (Stuart Smith LJ, Dove J) handed down judgment in a judicial review of a Coroner’s decision arising out of the tragic deaths of a mother and her young daughter who were hit by a train.

Following the inquest, the coroner returned a short-form conclusion of suicide in relation to the mother and a lengthy narrative-only conclusion in relation to the child, which included the following: “it was not possible to determine that [the mother] was not suffering from such a disease of the mind as to be incapable of distinguishing between right and wrong and was therefore likely to be legally insane.”

The Claimant, the child’s paternal aunt, argued that the coroner erred in adopting a presumption of insanity in relation to the mother, and contended that any conclusion other than a short-form conclusion that the child was unlawfully killed was irrational.

The claim was refused with the court finding that concepts of “presumptions” and “burdens of proof” were unsuitable to be applied to the deceased person or to interested persons involved in an inquest, for basic reasons of fairness. That was particularly the case where the person whose conduct was at issue was themselves the deceased and a subject of the inquest.

The Court held that the key questions for the coroner when addressing the issue of insanity in an inquest are:

  1. Whether on all the available evidence, the issue of insanity was properly raised and if so, is there is sufficient evidence of insanity for it not to be withdrawn from consideration (either by the coroner or, if there was one, the jury)?
  2. Whether, on all the relevant evidence, the correct conclusion on the balance of probabilities was that the person in question was not insane?

The court upheld the characterisation of the test set out in paragraphs 2 and 32 of the Chief Coroner’s Law Sheet No.1 on Unlawful Killing and the court held that paragraph 32 did not seek to introduce a presumption of sanity.

Nicholas Ostrowski appeared for the mother’s family (with Caoilfhionn Gallagher KC instructed by Merry Varney at Leigh Day) at both the judicial review and in the lengthy inquest.