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Wandsworth Borough Council, R (on the application of) v HM Senior Coroner For Inner West London
Factual and Procedural Background
On 27 August 2018, Mrs Johns died of bronchopneumonia at The Hospital. She had lived for many years at a council-owned property, 8 Eliot Court, known to have contained asbestos during her tenancy. A post-mortem examination by a consultant pathologist disclosed that the bronchopneumonia resulted from malignant mesothelioma, a cancer affecting the lung lining. The senior coroner for Inner West London held an inquest and concluded that Mrs Johns died from exposure to asbestos at 8 Eliot Court causing malignant mesothelioma.
The claimant council, as owner and landlord of 8 Eliot Court, challenged the coroner's conclusion that the mesothelioma resulted from asbestos exposure at that address. The claimant sought to quash the coroner’s findings and substitute a conclusion omitting any reference to asbestos. The coroner remained neutral and did not participate actively in the proceedings.
Mrs Johns was a tenant of the claimant authority from June 1989 until 2017, residing at 8 Eliot Court from July 1996. Asbestos was detected in the flat in 1984, prior to her tenancy. In 2003, asbestos removal and heating system replacement work was conducted at the property. Mrs Johns and her daughter vacated the flat during asbestos removal on 17 October 2003. A vacuum cleaner malfunctioned during this work, damaging some of Mrs Johns' possessions with a polymeric substance. Mrs Johns was present during subsequent radiator replacement work. She sought compensation for damaged possessions, which was settled.
Mrs Johns moved out in June 2017 and was diagnosed with metastatic adenocarcinoma in 2018, dying later that year. The hospital reported her death to the coroner due to her history of asbestos exposure. The coroner held a pre-inquest review and inquest hearing, admitting various documents including the post-mortem report, medical history, and evidence relating to asbestos presence and removal work. The coroner found on the balance of probabilities that asbestos exposure at 8 Eliot Court caused Mrs Johns' malignant mesothelioma and death, recording a narrative conclusion to that effect.
Legal Issues Presented
- Whether the coroner was entitled to conclude, on the balance of probabilities, that Mrs Johns developed malignant mesothelioma as a result of exposure to asbestos while living at 8 Eliot Court.
- Whether the evidence was sufficient to support the coroner’s finding that the asbestos exposure at 8 Eliot Court caused Mrs Johns' death.
- Whether the coroner correctly applied the legal standards for causation and sufficiency of evidence in making her findings and conclusion.
Arguments of the Parties
Claimant's Arguments
- Living in a property containing asbestos does not necessarily constitute exposure to asbestos fibres.
- No positive evidence showed Mrs Johns was exposed to freely circulating asbestos fibres during her tenancy at 8 Eliot Court.
- Other possible causes of malignant mesothelioma were not adequately excluded or addressed.
- Even if asbestos exposure caused the mesothelioma, it could have occurred elsewhere than at 8 Eliot Court.
- The coroner erred in relying on the pathologist’s opinion that it was "reasonable to assume" asbestos exposure at 8 Eliot Court caused the mesothelioma, as this was outside his expertise.
- The coroner failed to properly apply the 'Galbraith plus' test regarding sufficiency and safety of evidence for her findings.
- The coroner did not conduct an adequate inquiry into alternative explanations for Mrs Johns' illness.
Table of Precedents Cited
| Precedent | Rule or Principle Cited For | Application by the Court |
|---|---|---|
| R (S) v Inner West London Coroner [2001] EWHC 105 (Admin) | Coroner’s discretion in deciding whether evidence is fit to be left to a jury in inquisitorial proceedings. | Supported the principle that the claimant’s failure to challenge the coroner’s findings at inquest does not preclude later challenge in court. |
| R v HM Coroner for Greater London, ex parte Thomas [1993] QB 610 | Inquests cannot determine criminal or civil liability and are not forums for gathering evidence for such proceedings. | Reinforced the limited scope and purpose of coroner’s inquests. |
| R v HM Coroner for North Humberside and Scunthorpe, ex parte Jamieson [1995] Q.B. 1 | Coroner’s duty to fully, fairly, and fearlessly investigate relevant facts within resource constraints. | Guided the court’s view on the coroner’s investigative responsibilities and discretion. |
| R (Tainton) v HM Senior Coroner for Preston and West Lancashire [2016] EWHC 1396 (Admin) | Standard for causation in coroner’s inquests requires that the event more than minimally contributed to death. | Distinguished the test for causation in coronial investigations from civil liability standards. |
| R (Maughan) v HM Senior Coroner for Oxfordshire [2020] UKSC 46 | Standard of proof for factual findings in inquests is the balance of probabilities. | Confirmed the applicable standard of proof for coroner’s findings. |
| R v Galbraith [1981] 1 W.L.R. 1039 | Test for whether evidence is sufficient and safe to be left to a jury. | Referenced in relation to the coroner’s application of sufficiency and safety of evidence in findings. |
| Fairchild v Glenhaven Funeral Services Ltd and Others [2003] 1 AC 32 | In civil cases, liability may arise from materially increasing the risk of contracting disease. | Distinguished from coronial investigations where actual material contribution to death is required. |
Court's Reasoning and Analysis
The court analysed whether the coroner’s conclusion that asbestos exposure at 8 Eliot Court caused Mrs Johns’ malignant mesothelioma was supported by evidence on the balance of probabilities. It acknowledged the strong statistical association between asbestos exposure and mesothelioma but emphasized that statistical probability alone does not establish causation in a particular case.
The evidence showed asbestos was present in the property and that asbestos removal work occurred during Mrs Johns’ tenancy. However, Mrs Johns and her daughter were not present during the removal, and there was no direct evidence of exposure to freely circulating asbestos fibres. The dust found after the vacuum cleaner malfunction was of unknown composition, and the pathologist confirmed it was unlikely to have contributed to the illness.
The coroner’s assumption that Mrs Johns must have been exposed to asbestos fibres at some other time during her tenancy was unsupported by evidence. The court found that the evidence at best established a possibility, not a probability, that the mesothelioma was caused by asbestos exposure at 8 Eliot Court.
The court also noted that the pathologist’s statement that it was "reasonable to assume" causation was beyond his medical expertise and should not have been relied upon by the coroner. Additionally, given the long latency period and the commonality of asbestos, it was impossible to exclude other sources of exposure.
Overall, the court concluded the coroner’s findings were unreasonable as they placed greater weight on limited evidence than warranted and failed to meet the required standard of proof for causation in coronial proceedings.
Holding and Implications
The court's final decision was to QUASH the coroner's findings and conclusion that Mrs Johns' malignant mesothelioma was caused by asbestos exposure at 8 Eliot Court. The court substituted the findings with a conclusion that Mrs Johns was diagnosed with malignant mesothelioma in July 2018, which led to her death, without attributing causation to asbestos exposure at the property.
The direct effect is that the coroner’s narrative conclusion referring to asbestos exposure as the cause of death is removed. No broader precedent was established beyond clarifying the evidential standards and limits of coroner’s findings regarding causation in asbestos-related deaths.
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