Latest Case Law Round-Up of Challenges to Coronial decisions

Since our last legal update, the Administrative Court has been busy hearing challenges to coroners’ decisions. This article will provide a summary of key cases.

Cherfan v HM Senior Coroner for West London [2024] EWHC 3261 (Admin)

The High Court ruled in favor of Marc Cherfan’s family who brought a challenge to the Coroner’s conclusion of suicide. Mr Cherfan died from an overdose of prescription medication, which his family believed was accidental. The Coroner had conducted the inquest in open court by reading evidence submitted pursuant to Rule 23 of The Coroners (Inquests) Rules 2013 (“2013 Rules”). However, the Coroner had not notified the family of the hearing, and they therefore submitted this was procedurally flawed in accordance with Rule 9 of the 2013 Rules. 

The High Court agreed with Mr Cherfan’s family that this failure constituted a breach of Rule 9 as the decision failed to “take into consideration the family's view that Marc died not as a consequence of suicide but by accidental overdose”. The court also ordered the Coroner to pay the family’s legal costs of the application in the sum of £20,000 due to “an admitted breach of a mandatory provision of the Rules”.

This judgment emphasises the risk of adverse cost orders against coroners where flaws in process are found. 

R (on the applications of Sean Glaister and Mary Carr) v HM Assistant Coroner for North Wales [2025] EWHC 167 (Admin)

This inquest concerned the tragic death of Benjamin David Leonard, a 16-year-old scout who died during a camping weekend in Snowdonia. The jury concluded in the Record of Inquest (“ROI”) that “unlawful killing by the Explorer Scout Leader and Assistant Explorer Scout Leader contributed to by the Neglect of the Scout Association”. 

The Scout leaders referred to in the ROI sought to challenge the jury’s conclusion by arguing that the Coroner incorrectly applied the legal test for gross negligence manslaughter when directing the jury. The Court dismissed the claims on the following basis:

1. The issue of unlawful killing was an issue lawfully and properly left to the jury in respect of both Scout leaders;
2. The procedure adopted was such that the conclusions left to the jury were unlikely to confuse or cause misunderstanding, thus limiting the risk of a wrongful conclusion based on the evidence heard; 
3. The jury identified their agreed factual foundation for their conclusions in accordance with a clear and lawful direction from the Coroner. There was no doubt about the basis on which the jury was satisfied as to unlawful killing.

This judgment highlights the difficulty in challenging the jury’s conclusion when it has been properly directed by the Coroner.

Whittle v HM Coroner for North West Wales [2025] EWHC 236 (Admin)

The High Court quashed a 30-year-old inquest into the death of Anthony Joseph Whittle, who died in 1994 after escaping from a psychiatric unit. The original inquest returned an open verdict, but the deceased’s brother argued that there had been an insufficiency of inquiry. The Coroner supported the application. The Court agreed and ordered a fresh inquest. 

A significant procedural issue arose concerning the wrongful service of the claim form. The Attorney General’s fiat was issued on 5 January 2024 and the claimant had until 16 February (6 weeks) to file the claim with the Administrative Court pursuant to Part 8 of the Civil Procedural Rules. 

The claimant’s representative filed the claim at the Bristol Civil Justice Centre on 14 February 2024 and then served an unsealed claim form on the Coroner. The claim form was rejected by Bristol Civil Justice Centre as they required e-filing and so the claimant’s representative refiled in March but by this point, was out of time. The claimant’s representative also  at this point, applied for a relief from sanctions. The case was then transferred to the Administrative Court in London on 22 April 2024 but inadvertently transferred to Cardiff and then back to London. The sealed claim form was eventually served on the Coroner in June 2024 (4 months out of time).

 The Court found the relief from sanctions application was “misconceived”, as such an application did not apply to Part 8 claims. Although the Court also recognised delays with HM Court & Tribunal Service, they found the Claimant’s representative’s argument that a relief had been “impliedly” granted due to the transfer of the case from Bristol to London to be “without foundation”. 

Nevertheless, as the Coroner supported the application for a fresh inquest and the Claimant’s representative had taken timely steps to rectify the situation, the High Court decided to address the issue by extending the time for service. 

The judge handing down this judgment highlighted the importance of following the correct procedure if taking steps to seek an order for a fresh inquest (after obtaining the Attorney General’s consent). 

This article was written by Anusha Kasture, Jordan Coulton and Charlotte Whitaker. 

Please do not hesitate to get in touch with the team should you wish to discuss any inquest matters further.