Shafi v HM Senior Coroner for East London

Factual and Procedural Background

This is an application brought by the Plaintiff, with the fiat of the Solicitor General under section 13 of the Coroners Act 1988 (as amended), to quash the inquest into the death of her son and to order a fresh investigation and inquest.

The deceased died in custody at a police station prison in Dubai, United Arab Emirates, on 12 April 2011. An inquest was held on 10 October 2013 by the then senior coroner for the East London coroner area, who recorded an open conclusion with the medical cause of death described as "unascertained".

The Plaintiff submitted that the inquest was insufficient due to inadequate inquiry by the coroner, specifically in evidence collection, limited witness calling, and questioning. The Plaintiff also alleged procedural irregularities, including the coroner’s decision to conduct the inquest without a jury and to admit written evidence from Dubai.

The coroner assumed jurisdiction once the deceased’s body was returned to the East London area, pursuant to established legal principles that coroners must investigate certain overseas deaths when the body is repatriated. The coroner sought evidence from Dubai authorities through the Foreign and Commonwealth Office, including autopsy reports, witness statements, and CCTV footage, but CCTV footage was never produced despite multiple requests.

The coroner admitted written evidence from Dubai witnesses under Rule 23 of the Coroners (Inquests) Rules 2013, without calling those witnesses to give live evidence. The coroner decided not to summon a jury, concluding the mandatory provisions did not apply to deaths in custody abroad and that the case was not sufficiently complex to justify a jury.

The Plaintiff contended that the coroner’s inquiries were insufficient and that a jury should have been summoned. The court found that a pre-inquest review hearing should have been held to address outstanding issues but was not.

Legal Issues Presented

1. Whether the coroner’s inquiry into the death was sufficient, particularly regarding the collection of evidence and witness attendance.
2. Whether the coroner erred in admitting written evidence from overseas witnesses without exploring alternatives such as live or video-link attendance.
3. Whether the coroner was required to summon a jury for the inquest under section 7 of the Coroners and Justice Act 2009, given the death occurred in custody abroad.
4. Whether the failure to hold a pre-inquest review hearing constituted an irregularity affecting the fairness of the proceedings.

Arguments of the Parties

Appellant's Arguments

• The coroner’s inquiry was insufficient due to inadequate efforts to obtain CCTV footage and failure to secure attendance of key Dubai witnesses.
• The admission of written evidence under Rule 23 was improper because the coroner did not adequately explore whether witnesses could attend live or by video link.
• The coroner should have summoned a jury because the death occurred in custody and the cause of death was unknown, invoking mandatory provisions under section 7(2)(a) of the Coroners and Justice Act 2009.
• The failure to hold a pre-inquest review hearing deprived the parties of a proper forum to address important procedural and evidential issues prior to the inquest.

Respondent's Arguments

• The coroner took sufficient steps to obtain evidence, including multiple formal and informal requests for CCTV footage and other documents through diplomatic channels.
• The coroner lawfully admitted written evidence under Rule 23, having reasonable grounds to believe witnesses from Dubai would not attend the inquest.
• The mandatory jury provisions of section 7(2)(a) do not apply to deaths in custody occurring outside the UK; the coroner correctly exercised discretion not to summon a jury.
• The failure to hold a pre-inquest review hearing was not an irregularity of proceedings, though such a hearing might have been preferable for case management.

Table of Precedents Cited

Precedent	Rule or Principle Cited For	Application by the Court
R v West Yorkshire Coroner, ex parte Smith [1983] QB 335	Coroners' duty to investigate deaths overseas when the body is repatriated.	Confirmed that coroners have jurisdiction to investigate deaths abroad under certain conditions and face evidential difficulties in such inquiries.
Re Neal (1995) 37 BMLR 164	Discretion to summon a jury in inquests involving deaths abroad and public safety concerns.	Considered but found obiter regarding mandatory jury requirement for deaths in custody abroad; relevant for discretionary jury considerations.
R (Paul) v Deputy Coroner for the Queen's Household and Assistant Deputy Coroner for Surrey [2008] QB 172	Requirement to summon a jury under section 8(3)(d) of the Coroners Act 1988 for certain deaths.	Discussed jury requirement in high-profile inquest; did not resolve jury requirement for deaths in custody abroad but provided guidance on discretionary factors.

Court's Reasoning and Analysis

The court acknowledged the inherent difficulties coroners face in obtaining evidence from foreign jurisdictions, including lack of power to compel witnesses or documents overseas. The coroner made multiple documented efforts to obtain CCTV footage and other evidence through diplomatic channels but ultimately did not receive the footage.

However, the court found that the coroner failed to adequately explore alternatives to live attendance of Dubai witnesses, such as attendance by video link, before admitting their written evidence under Rule 23. The coroner did not specify the "good and sufficient reason" for believing the witnesses would not attend, nor did he explain the nature of discussions with Dubai authorities. This was deemed a significant failure in due process and an insufficiency of inquiry under section 13 of the Coroners Act 1988.

Regarding the jury issue, the court considered the statutory framework under the Coroners and Justice Act 2009. It concluded that the mandatory jury provisions for deaths in custody do not extend to deaths occurring abroad, as the statutory definitions and legislative policy focus on UK institutions and agents of the State. The court emphasized that the policy rationale for mandatory juries is linked to scrutiny of domestic state agents, which does not apply with the same force to foreign states.

The court noted that the discretion to summon a jury remains, but declined to rule on whether it should have been exercised in this case, leaving that decision to the new coroner at the fresh inquest.

The court also criticized the absence of a pre-inquest review hearing, which would have been appropriate given the case’s complexity and outstanding issues. Although not constituting an irregularity of proceedings, the failure to hold such a hearing was a missed opportunity for better case management and public transparency.

Holding and Implications

The court QUASHED the conclusions of the inquest held on 10 October 2013 into the death of the deceased and ordered a fresh investigation and inquest to be conducted by the new senior coroner for the East London coroner area.

The direct effect of this decision is to require a new inquest with a more thorough inquiry, including better efforts to secure attendance of overseas witnesses and reconsideration of whether a jury should be summoned. No new binding legal precedent was established, but the judgment clarifies the limits of mandatory jury requirements for deaths in custody abroad and underscores the importance of procedural fairness in admitting written evidence under Rule 23.