Bilski, R (On the Application Of) v HM Coroner for Inner West London

Factual and Procedural Background

This opinion concerns a renewed application for permission for judicial review relating to an Inquest conducted by HM Assistant Coroner for Inner West London. The Coroner made a decision on 15 April 2021 refusing to adjourn the Inquest to allow the instruction of an expert in vascular neurosurgery and addressed findings recorded in the Inquest record regarding the circumstances of the deceased's death. The deceased, a 32-year-old woman, died on 13 March 2016 from a sub-arachnoid haemorrhage. The dispute centers on the adequacy of the Record of Inquisition, specifically the content of box 3, which states where and when the death occurred but omits detailed explanation of how the death occurred. The claimant challenges this omission as rendering the Record unlawful and also contests the Coroner's refusal to adjourn for further expert evidence.

Legal Issues Presented

1. Whether the omission of an explanation of "how" the deceased died in box 3 of the Record of Inquisition renders the record unlawful.
2. Whether the Coroner erred in refusing to adjourn the Inquest to instruct a vascular neurosurgery expert.

Arguments of the Parties

Appellant's Arguments

• Box 3 of the Record of Inquisition is fundamentally defective because it only states where and when the deceased died without explaining how.
• The preceding medical history, including a diagnosis of a carotid aneurysm about a month before death and subsequent treatment decisions, should be reflected in box 3 to explain how the death occurred.
• The refusal to adjourn the Inquest to instruct a vascular neurosurgery expert was improper, as such expertise was necessary to address the relevance of the aneurysm to the cause of death.

Respondent's Arguments

• The cause of death and how it occurred were sufficiently recorded in the Record of Inquisition, particularly in boxes 2 and 4, which indicate a natural death by brain bleed (intracerebral haematoma) resulting from aneurysm rupture.
• The Inquest’s scope was limited to the immediate circumstances of death (how, when, and where), and the preceding medical history did not bear on these questions.
• The Coroner had appropriate expert evidence from a consultant neurosurgeon, and the vascular sub-specialty was not necessary to resolve the issues before the Inquest.

Table of Precedents Cited

No precedents were cited in the provided opinion.

Court's Reasoning and Analysis

The court began by clarifying the scope of the Inquest as limited to the immediate circumstances of the deceased’s death—specifically how, when, and where the death occurred. It found that the Record of Inquisition adequately addressed these points, with box 3 correctly recording the place and date of death and boxes 2 and 4 adequately explaining the cause and nature of death as a sub-arachnoid haemorrhage due to aneurysm rupture.

The court acknowledged a technical defect in box 3 regarding the absence of a cross-reference to box 4 but concluded this did not amount to a fundamental flaw or unlawfulness in the Record. The claimant's argument to include the preceding diagnosis and treatment history in box 3 was rejected as irrelevant to the limited scope of the Inquest.

Regarding the refusal to adjourn for a vascular neurosurgery expert, the court reasoned that such an expert was unnecessary because the Coroner had sufficient expert evidence from a consultant neurosurgeon competent to address the cause of death. The vascular sub-specialty was not critical since the aneurysm was considered background information and did not affect the immediate cause of death determination.

Accordingly, both grounds for judicial review were found to be not arguable, and permission was refused.

Holding and Implications

The court REFUSED PERMISSION for judicial review on both grounds presented by the claimant.

The direct effect of this decision is to uphold the Coroner’s Record of Inquisition as lawful and to affirm the Coroner’s refusal to adjourn the Inquest for further expert evidence. No broader legal precedent was established, and the ruling confirms the limited scope of Inquest records and the discretion of the Coroner in managing expert evidence.