Newsletters Professional Discipline 31st May 2023

The consideration of “why” in cases of Suicide – Dove v HM Assistant Coroner for Teesside and Hartlepool [2023] EWCA Civ 289

Jodey Whiting died in February 2017 as a result of an overdose. She had a complex history of physical and mental health problems.  Her death came two weeks after her benefits were stopped by The Department for Work and Pensions (DWP) because she did not attend a Work Capability Assessment.

Following an inquest in May 2017 the Coroner recorded Jodey’s death as a suicide. Jodey’s mother, Joy Dove, made plain that she believed that the stress caused by DWP’s decision to withdraw benefits had been a contributing factor to her death. The Coroner ruled that it was not her function to question any decisions made by the DWP.

In December 2020 Ms Dove, with the Attorney General’s permission, applied under section 13 of the Coroners Act 1988 to quash the Coroner’s determination and order a new inquest. She relied on two pieces of fresh evidence:

  1. An Independent Case Examiner had reviewed the DWP’s handling of Jodey’s case, detailing a number of criticisms of their conduct before and after her death. Those criticisms, described as “shocking” in the High Court, included breaches of the Department’s own guidance for dealing with vulnerable claimants. It was now accepted that DWP should not have stopped Jodey’s benefits.
  2. An expert report from a consultant psychiatrist concluded that Jodey’s vulnerabilities would have been “substantially affected” by the decisions of the DWP and that on the balance of probabilities “there was likely to have been a causal link between the [DWP’s] failings…and [Jodey’s] state of mind immediately before her death.” The report did not go as far as to say that the DWP’s decision to stop Jodey’s benefits caused her to take her own life. He did not rule out other stressors as causative of her suicidal state or her suicide.

The Divisional Court refused the application, which was renewed before the Court of Appeal.

The Fresh Evidence

The Coroner’s decision that the DWP’s failings were not relevant to the inquest she was conducting was not criticised by the CoA. Whilst a fresh inquest might admit the Independent Case Examiner’s report to establish the sequence of events preceding Jodey’s death, an investigation of the DWP’s conduct, including the individual failings, would lie beyond the scope of any non-Article 2 inquest.

The “why” question

Where the decision becomes particularly significant is in the extent to which a Coroner is required to consider why a person took their own life.

The CoA found that the Divisional Court had erred in drawing a sharp distinction between Jodey’s mental health prior to death and her death by suicide. Jodey’s suicide was the end point to which her mental health problems brought her. The psychiatric report was, therefore, relevant to her death not simply, as the Divisional Court had found, to her state of mind before her death. Causation is a broader concept, which encompasses acts or omissions which contribute (more than trivially) to death and it is open to a coroner in a suicide case to consider the extent to which acts or omissions contributed to the deceased’s mental health deterioration.

The CoA rejected the Coroner’s submission that an inquest is not permitted to investigate the cause of mental health deterioration or the impact of past events on a person’s mental health in a suicide case. To do so did not, in the CoA’s view, represent an extension of the law:

  • There is a wide discretion conferred on coroners to establish the background facts. It is then open to a coroner to record the facts which contributed to the circumstances which may or may not in turn have led to death.
  • There is no distinction between physical causes and psychiatric causes which might have exacerbated mental illness: the discretion to consider contributory factors cannot depend on the form those factors take.
  • It would be undesirable to restrict a coroner’s discretion to conduct whatever investigations are appropriate within the ambit of a Jamieson inquest to establish “how” the deceased came by their death.
  • Where suicide is raised as a possible verdict, part of the coroner’s role is to investigate whether the deceased intended to take their own life, and that will often lead to a consideration of whether the deceased acted while their mind was disturbed, with that fact being recorded if it is established. An investigation of the cause or causes of disturbance of the mind may therefore be part of, or lie very close to, the matters which are already before the coroner.

The Court decided it was desirable to hold a new inquest because of the real significance the issue had to the family, the public interest in the Coroner considering the broader issue of the DWP’s approach to cutting off the benefits of vulnerable people, and the possible PFD issues that might flow from that.


Nikita McNeill


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