McLeish, R (on the application of) v HM Coroner for the Northern District of Greater London

Factual and Procedural Background

This judicial review claim was brought against Her Majesty's Coroner for the Northern District of Greater London. Permission to proceed was granted after an oral hearing. The claimant is the mother of a deceased adult son who was found dead in a marsh area. Prior to his death, he had been reported missing for several months. Following the discovery of the body, the claimant was informed by the Coroner's Officer and was given assurances that blood tests would reveal the cause of death. An autopsy was conducted and an inquest was opened and adjourned shortly thereafter. The claimant was kept under the impression that the cause of death investigation was ongoing and that she would be informed of the results. However, there were significant delays and failures in communication by the Coroner's Office, including the non-disclosure of post mortem and toxicology reports to the claimant. The claimant arranged the funeral without the cause of death being ascertained and later sought information and copies of reports, which were only provided after months of delay. The inquest was eventually held over a year after the death, concluding with an open verdict due to the inability to determine the cause of death. The Coroner publicly apologized for the delays and failings. The claimant then sought judicial review on grounds including breach of common law, Coroners Rules, and violation of Article 8 of the European Convention on Human Rights.

Legal Issues Presented

1. Whether the defendant Coroner breached common law duties by failing to inform the claimant of the existence and contents of the post mortem and toxicology reports in a timely manner.
2. Whether the defendant breached Rule 57 of the Coroners Rules 1984 by failing to supply the claimant, as a properly interested person, with copies of the post mortem reports upon application.
3. Whether the defendant violated the claimant's rights under Article 8 of the European Convention on Human Rights regarding respect for private and family life in the context of notification and disclosure related to the death investigation.

Arguments of the Parties

Appellant's Arguments

• The claimant argued that delays and failures in communication caused her detriment, preventing her from making informed decisions about further post mortem examinations or toxicological analyses.
• The claimant relied on the common law principle that fairness requires proper procedural safeguards when administrative decisions cause detriment.
• She contended that the Coroner breached Rule 57 of the Coroners Rules by not supplying reports despite her applications and that the failure to notify her of the reports’ existence was a breach of duty.
• The claimant submitted that the delay undermined the statutory purpose of inquests to ascertain causes of death.
• She also argued that the defendant breached the guidance in Home Office Circular 30 of 1999 regarding timely provision of post mortem reports to interested parties.
• Regarding Article 8, the claimant asserted that the right to know the cause of death and to be informed about the death investigation engaged her private and family life rights under the European Convention on Human Rights.

Respondent's Arguments

• The defendant submitted that no breach of common law arose because the claimant could have requested a second post mortem or further analyses independently of receiving the Coroner’s reports.
• It was argued that the Coroner has discretion over disclosure of reports and that no formal application with payment of fees had been made by the claimant, negating breach of Rule 57.
• The defendant maintained that the Home Office Circular was a memorandum of good practice, not a binding policy, and that the case did not concern a suspicious death within the Circular’s scope.
• Regarding Article 8, the defendant contended that the claimant’s situation was materially different from established cases and that no violation occurred.
• It was also submitted that the Coroner who conducted the inquest was not personally involved in the failures and that remedial measures had been introduced subsequently.

Table of Precedents Cited

Court's Reasoning and Analysis

The court carefully reviewed the factual timeline, particularly focusing on the claimant's repeated requests for information and the defendant’s failure to provide timely updates or copies of reports. It found that the claimant was given assurances that she would be informed of the post mortem and toxicology results, which were not fulfilled, resulting in a procedural failure that caused detriment to the claimant. The court acknowledged the Coroner’s discretion over disclosure but held that in circumstances where the claimant persistently sought information, a duty arose to notify her of the existence of the reports and provide them upon request. The court also examined relevant statutory provisions and Coroners Rules, concluding that the defendant breached Rule 57 by failing to supply reports without demanding payment or explaining fees. The court distinguished prior case law limiting disclosure in coronial proceedings, emphasizing that this case involved a bereaved family member seeking basic information rather than a charged party. Regarding the Article 8 claim, the court found the cited authorities to be materially different and ruled that the claimant’s situation did not engage Article 8 rights to a sufficient extent to establish a violation. The court accepted the apology and remedial steps taken by the Coroner but stressed the importance of procedural fairness and communication in cases of unascertained deaths.

Holding and Implications

The court granted the claimant's application for a declaration that the defendant had acted in breach of the common law and Rule 57 of the Coroners Rules 1984 by failing to inform and supply the claimant with relevant post mortem reports in a timely manner. The claim under Article 8 of the European Convention on Human Rights was dismissed as not applicable on the facts.

Costs were ordered to remain as between the parties, with no order for costs awarded to either side.

The direct effect of this decision is to affirm the duty of coroners to notify interested persons who have made clear requests for information about the existence of post mortem reports and to supply such reports without undue delay and without imposing unreasonable procedural hurdles. The judgment does not establish a general right to disclosure absent an application but emphasizes the need for procedural fairness in handling bereaved relatives’ requests. No new precedent was set regarding Article 8 rights in this context, and the ruling is confined to the specific circumstances of unascertained death and the claimant’s persistent requests.