News Inquests & Public Inquiries 15th May 2019

Newsflash: Inquest Update

2018 Coroners Statistics

At the end of last week, the Ministry of Justice and the Office of National Statistics published the Annual Coroner statistics for 2018.

The key findings were these:

  • There was a 4% decrease in deaths reported to coroners in 2018 reflecting the removal of DoLS (Deprivation of Liberty Safeguards) cases being reported to Coroners.
  • There was a 3% decrease in deaths in state detention (excluding DoLS), 513 deaths were reported to coroners in 2018 (down from 528 the year before). The decline is driven by a 13% fall in deaths of individuals under the Mental Health Act 1983.
  • There was an 8% decrease in the number of inquests opened in 2018 (29,100). This was driven by DoLS deaths no longer being reported to coroners, which prior to the 2009 Act amendment, required an inquest, as all state detention deaths do.
  • There were 423 inquests held with juries in 2018 (representing 1% of all inquests), a decrease of 16% compared to 2017.
  • The average time taken to process an inquest rose by 5 weeks from 21 weeks in 2017 to 26 weeks in 2018.

The Standard for Suicide Confirmed

Last week the Court of Appeal in R(Maughan) v Senior Coroner for Oxfordshire [2019] EWCA Civ 809 upheld the decision of the Divisional Court that the civil standard of proof is to be applied to findings of Suicide (whether short form or in a narrative) and the criminal standard of proof now only applies to the conclusion of Unlawful Killing. For the full judgment click on this link

Ella Kissi-Debrah: New Inquest to be held into “Air Pollution” Death

 Ella Kissi-Debrah died on 15th February 2013 from a severe asthma attack. She was 9 years old. It is reported that Ella lived 25 metres from the South Circular road in Lewisham and prior to her death had attended hospital 27 times for her asthma attacks.

At the original inquest the medical cause of Ella’s death and the medical care provided in the short time between the asthma attack and death were considered. It was concluded that Ella suffered an asthma attack followed by a seizure and died after unsuccessful resuscitation.

An application was made under the authority of a fiat granted by the Attorney General for an order pursuant to Section 13 of the Coroner’s Act 1988 quashing the original inquest and directing a fresh investigation pursuant to part 1 of the Coroners and Justice Act 2009. Section 13 of the 1988 Act gives the High Court the power to quash a finding made at an inquest and direct a further investigation into a death if the court is satisfied: “that (whether by reason of fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, the discovery of new facts or evidence or otherwise) it is necessary or desirable in the interests of justice that an investigation (or as the case may by, another investigation)should be held”. It was submitted that new evidence had come to light since the original inquest relating to the extreme air pollution in the area where Ella lived and the contribution of this to her severe asthma and her death. This was supported by the expert report of a professor of immunopharmacology and consultant respiratory physician which concluded that it was likely that unlawful levels of air pollution contributed to the cause and the severity of Ella’s fatal asthma attack and that there was a real prospect that without unlawful levels of air pollution, Ella would not have died. It was submitted that there was an arguable failure by the state to reduce the air pollution which was connected to Ella’s death. Reference was made to R (Client Earth) v Secretary of State for the Environment, Food and Rural Affairs [2013] UKSC 25 in which the Supreme Court explained that the statutory limit values for Nitrogen Dioxide and other harmful particulates set out in the Air Quality (Standards) Regulations 2010 were imposed specifically to prevent deaths and that the government was in breach of its obligations to comply. Indeed, the Administrative Court has since reiterated that the government must produce action plans which address the breach and reduce exposure as quickly as possible (R (Client Earth) v Secretary of State for the Environment, Food and Rural Affairs (No.3) [2018] EWHC 315 (Admin)). The High Court ruled that the discovery of this new evidence made it necessary in the interests of justice that the original inquest be quashed and a fresh inquest be held.

This inquest is set to be a significant and timely milestone in the battle against air pollution which is believed to cause or contribute to as many as 40,000 deaths a year in the UK. This along with the nearly 40 million people in the UK reported to be living in areas where illegal levels of air pollution risk damaging their health[1] means that this inquest is likely to be the first of many which will highlight the contribution of air pollution to premature deaths placing further pressure on the Government to turn climate change declarations into action.


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