Case Note in O’Brien v HM Assistant Coroner for Sefton, Knowsley and St Helens [2025] EWHC (Admin)

Background

In summary, Linda O’Brien had died on 9 May 2020 after falling from the window of her flat on the fourth floor. It was likely that she was intoxicated at the time.

Present in her flat was also Mr McMahon (her former partner). By way of background, several months before Ms O’Brien’s death, he had been convicted of assaulting her. A restraining order was in place which prevented him from contacting her. Furthermore, one month before her death on 7 April 2020, police attended Ms O’Brien’s flat following reports of a disturbance. Mr McMahon was found drunk at the address, but Ms O’Brien explained that there was no disturbance. The police were unaware that Mr McMahon was subject to a restraining order and in breach of it.

Turning to her injuries, whilst the majority of them were consistent with a fall, there were some injuries to the right side of her face which would be consistent with having been punched or slapped. Indeed, there was some evidence that prior to her fall she may have been struck with a weapon on the left shoulder and right shin. Given these injuries, and that Mr McMahon was the only other person present in the property, he was arrested on suspicion of attempted murder but later released on bail. Ultimately, he was sentenced to 20 months’ imprisonment for breach of the restraining order and for theft but the case against him for attempted murder was dropped.

Issues and challenge

The scope of the inquest became a key issue in this case. The coroner was invited to investigate whether omissions by the police on 7 April (failure to recognise that Mr McMahon was in breach of a restraining order and failure to subsequently arrest) had contributed to Ms O’Brien’s death.

The Assistant Coroner did not include the events of the 7 April as part of the scope of the inquest. Instead, the scope was limited to the events of 8 and 9 May, with information relating to 7 April and the restraining order being for background purposes only. It was determined that what may or may not have happened if Mr McMahon had been arrested on 7 April was purely speculative.

The Assistant Coroner’s decision to limit the scope of the inquest in this way was challenged. It was submitted that if the police were aware of the restraining order on 7 April, and subsequently arrested him, he would not have been at the property a month later. Moreover, it was argued that the coroner should have obtained expert evidence on the issue, and this evidence could have been left to a jury for them to determine whether omissions by the police on 7 April contributed to Ms O’Brien’s death.

Ultimately, the application for judicial review was dismissed at the High Court.

It was held that obtaining any expert evidence on the issue would be speculative. Moreover, there were a number of unknowns in relation to the ultimate outcome of 7 April. For example, he may have been granted bail, or he may not have been, or he may have breached any bail conditions in light of his approach and attitude towards the terms of his restraining order.

The Judge found that the scope of the enquiry was rational [paragraph 47(a)] and the investigation proposed by the claimant was irrelevant because “it could not be proved on the balance of probabilities that anything done or not done by the officers on 7 April or subsequently more than minimally, negligibly or trivially contributed to Linda’s death” [para 47(c)]. Moreover, “The investigation proposed by the claimant would be extremely wide ranging and complex. Since the inquest is an “inquisitorial and relatively summary process” and “not a surrogate to a public inquiry,” a decision to limit the scope of the enquiry to avoid this expensive and time-consuming investigation is consistent with the purpose of an inquest and could not be said to be irrational.” [para 47(b)].

A further matter was whether there was reason to suspect that the death resulted from an act or omission of a Police Officer so as to require a jury. The Judge agreed with the coroner that a jury was not required.

The Judge stated “The Coroner rejected the suggestion that there was a reason to suspect that Linda’s death resulted from an act or omission of a Police Officer. In my view, it is clear that he did so, not because there was no reason to suspect that an Officer’s acts or omissions might be criticised, but because the causative link between any alleged act or omission and Linda’s death was not (and could not be) established: that is what he said (“it is my opinion that the death did not result from an act or omission of a Police Officer” — my emphasis) and that is why he dealt with coronial causation in his directions. Since I do not believe that it is possible to obtain reliable evidence that would enable the coroner or the jury to be satisfied on the balance of probabilities that Mr McMahon would have been in custody on 9 May, had he been arrested earlier, I think the Coroner was entitled to reach the conclusion that he did. I do not consider his decision to be premature or irrational.” [para 46].

Commentary

This decision highlights the crucial and significant difference between possibility and speculation. The former supported by some evidence (e.g. the injuries recorded in relation to Ms O’Brien prior to her fall) and the latter supported by none (e.g. the involvement of the police one month prior to her death). The extent of the Coronial duty remains including possibly causative matters but not matters which have no more than a speculative link.