Silvera, R (on the application of) v HM Senior Coroner for Oxfordshire

Factual and Procedural Background

This judicial review concerns the decision of the Senior Coroner for Oxfordshire not to resume the inquest into the death of Ms. Baker, the mother of the Plaintiff. The Plaintiff challenged this decision as unlawful, alleging breaches of investigative duties under Article 2 of the European Convention on Human Rights and common law obligations to fully investigate the death.

Ms. Baker died in violent or unnatural circumstances around 16th August 2012. An inquest was initially opened but adjourned pending a police criminal investigation. The daughter of Ms. Baker, referred to as "K," pleaded guilty to manslaughter on the basis of diminished responsibility and was detained under a hospital order. K later died in 2014 from deep vein thrombosis.

Two investigations were conducted into the role of public authorities: a Root Cause Analysis Investigation Report by Oxford Health NHS Foundation Trust and a Domestic Homicide Review (DHR) by the Oxford Safer Communities Partnership. Both investigations were conducted privately and confidentially.

On 1st July 2014, the Senior Coroner certified that the inquest would not be resumed. Following requests from the Plaintiff's solicitors, the Senior Coroner sought further information but ultimately decided on 10th February 2016 not to resume the inquest. The Plaintiff initiated judicial review proceedings challenging that decision.

Legal Issues Presented

1. Whether the Senior Coroner applied the correct legal test in deciding not to resume the inquest into Ms. Baker's death.
2. Whether the investigations relied upon by the Senior Coroner discharged the investigative duty under Article 2 of the European Convention on Human Rights.
3. Whether the Senior Coroner's decision was lawful and rational in light of the common law duty to fully investigate deaths occurring in violent or unnatural circumstances.

Arguments of the Parties

Appellant's Arguments

• The Senior Coroner applied an incorrect test by focusing on whether the facts of the death had been adequately aired in public, rather than whether there was sufficient reason to resume the inquest as required by statute.
• The investigations relied upon by the Senior Coroner—the Crown Court proceedings (which were in fact a plea hearing, not a trial) and two private internal investigations—were insufficient to satisfy the investigative obligations under Article 2 of the Convention.
• The decision not to resume the inquest was therefore unlawful, irrational, and in breach of both Article 2 investigative duties and common law obligations.

Senior Coroner's Position

• The Senior Coroner took a neutral stance and was not represented at the hearing.
• Summary grounds submitted on his behalf indicated that he considered the combination of the Crown Court plea hearing and the two investigations sufficient to discharge the Article 2 investigative duty.
• He relied on the discretion afforded by the Coroners and Justice Act 2009 and case law, particularly the decision in R. v. Inner West London Coroner, ex parte Dallaglio, in deciding not to resume the inquest.

Table of Precedents Cited

Court's Reasoning and Analysis

The court analysed the Senior Coroner's decision under both statutory and Convention law frameworks. It found that the Senior Coroner applied the wrong legal test by focusing on whether the facts had been adequately aired in public, rather than whether there was sufficient reason to resume the inquest as required by paragraph 8 of Schedule 1 to the Coroners and Justice Act 2009.

Regarding the Article 2 investigative duty, the court confirmed that this duty was triggered by the circumstances of Ms. Baker's death. The court rejected the Senior Coroner's view that the combination of the Crown Court plea hearing and two private investigations discharged this duty. The Crown Court proceedings were not a trial exploring all relevant issues, and both investigations were conducted in private without independent expert input or meaningful family participation.

The court relied heavily on the House of Lords decision in R. (Amin) v. Secretary of State for the Home Department, which established that effective investigations under Article 2 must be independent, public, and allow for family participation. The court noted that the investigations here fell short of these minimum standards, and no inquest had been held to fulfill the investigative role.

Consequently, the court concluded that the Senior Coroner's decision was unlawful and irrational, breaching both the Convention and common law duties. It held that the inquest should have been resumed to properly discharge the investigative obligation.

Holding and Implications

The court allowed the claim for judicial review, holding that the Senior Coroner's decision not to resume the inquest was unlawful and in breach of Article 2 ECHR and common law investigative duties.

The direct effect of this decision is that the Senior Coroner must resume the inquest into Ms. Baker's death. The court did not establish new precedent but reaffirmed the established legal principles requiring effective, independent, and public investigations into deaths occurring in violent or unnatural circumstances, particularly where Article 2 is engaged.