O'Brien, R (On the Application Of) v HM Assistant Coroner for Sefton, Knowlsey and St Helens

Factual and Procedural Background

The Deceased died in the early hours of 9 May 2020 after falling from a flat window. An Individual identified in the proceedings as an Interested Person was present in the flat shortly before the death; he called emergency services after the fall. A coronial investigation opened and the Respondent (the coroner) decided, following written submissions, that the Interested Person, the Deceased's next of kin (the Appellant) and the Interested Party (the police entity) were interested persons, that the Inquest should be heard without a jury, and that Article 2 ECHR was not engaged. The Respondent limited the scope of the Inquest to events on 8 and 9 May 2020, treating earlier events from 7 April 2020 as background.

The Appellant sought judicial review of the scope decision, advancing multiple grounds. Permission was granted in the High Court only in relation to the ground alleging that the Respondent had prematurely and irrationally concluded there was no causative connection between the acts or omissions of the Interested Party (the police) on 7 April 2020 and the Deceased's death on 9 May 2020, thereby unlawfully limiting scope. The High Court judge dismissed the claim on that ground. The Appellant appealed to the Court of Appeal.

Legal Issues Presented

1. Whether the Respondent acted unlawfully (prematurely and irrationally) in concluding that there was no causative connection between the acts or omissions of the Interested Party on 7 April 2020 and the Deceased's death on 9 May 2020, thereby limiting the scope of the Inquest to 8–9 May 2020.
2. Whether the High Court judge erred in substituting his own factual findings on causation rather than reviewing the lawfulness of the Respondent's scope decision.

Arguments of the Parties

Appellant's Arguments

• The Inquest should investigate whether acts or omissions by the Interested Party on or after 7 April 2020 more than minimally contributed to the Deceased's death on 9 May 2020.
• The Respondent's decision to exclude investigation of events from 7 April was premature and irrational because it relied on an asserted inability to establish, on the balance of probabilities, that an arrest would have resulted in the Interested Person being detained on 9 May 2020 without first investigating accessible material (notably antecedents/PNC records) and sentencing practice.

Respondent and Interested Party's Arguments

• The Respondent (endorsing submissions from the Interested Party) said (summary of points (a)–(h) given in pre-action correspondence):
• (a) Individual alleged errors or omissions by the police could not be said to have been causative of a death occurring more than a month later.
• (b) Best‑case scenario would be arrest on 7 April 2020.
• (c) It is speculative that arrest would have prevented the Interested Person being with the Deceased on 9 May 2020.
• (d) It cannot be known that arrest would have led to incarceration before or on the date of death or deterred reattendance.
• (e) The systemic framework was present and there was no sufficient causative link to an alleged systemic duty breach.
• (f) It was not arguable the police failed to take steps within their powers that would have avoided the risk.
• (g) Although the restraining order was initially overlooked, officers later recognised the oversight and took steps likely to result in action within a month; those steps were proportionate.
• (h) Any connection between earlier arrest and the death was speculative.

Table of Precedents Cited

Court's Reasoning and Analysis

The Court of Appeal (Judge Edis delivering the leading judgment) reviewed the Respondent's Decision Notice and the High Court judge's treatment of the permitted ground. The court identified two overlapping errors in the Respondent's and the High Court judge's approaches:

1. The Respondent's causation conclusion was insufficiently reasoned and, in pre-action correspondence, rested on an assertion that it could not be known, on the balance of probabilities, that arrest on 7 April would have led to detention on 9 May. The Respondent reached that conclusion without investigating readily available material (notably the Interested Person's antecedents/PNC record) or considering relevant sentencing guidance and prosecutorial practice. That omission made the conclusion premature and irrational.
2. The High Court judge erred by substituting his own factual findings on causation instead of reviewing whether the Respondent's decision was lawful (i.e. whether it was premature or irrational). The judge formed his own view that it was speculative to conclude the Interested Person would have been in custody on 9 May, but did so without the focused review of the Respondent's reasoning and without requiring the investigation of antecedent material that could have informed the balance of probabilities assessment.

The court explained that the proper approach to the causation question under Tainton is to ask whether, on the balance of probabilities, the conduct in question more than minimally contributed to death. The court held that some evidence (post‑mortem bruising inconsistent with fall, witness evidence about escape route, history of controlling behaviour) provided a proper basis to investigate whether the Interested Person's presence contributed to the Deceased's fall. Because the Respondent had not examined antecedents and sentencing consequences, the Respondent's conclusion that causation could not be established on the balance of probabilities was based on incomplete inquiry.

The court further considered sentencing guidance and the actual outcome of a prior arrest (August 2019) to show that, on a rational assessment informed by sentencing guidelines and antecedents, it was probable the Interested Person would have been detained by 9 May if arrested on 7 April. The court rejected the High Court judge's categorical exclusion of expert evidence on the likely progress of prosecution and sentencing, noting expert evidence is admissible where it fills a gap in judicial knowledge.

On these bases the court concluded the Respondent exercised discretion on scope upon a false view of facts and in ignorance of key materials; the decision was therefore unlawful and required reconsideration.

Holding and Implications

APPEAL ALLOWED; DECISION QUASHED

Holding: The Court of Appeal allowed the appeal, quashed the Respondent's Decision Notice concerning causation and scope, and remitted the matter for reconsideration by another coroner.

Implications: The remittal requires the Respondent's earlier decisions (including whether to sit with a jury and whether Article 2 ECHR is engaged) to be reconsidered because they were premised on the now-quashed causation conclusion. The court indicated that investigation of the police conduct should not have been excluded without first examining antecedent records and relevant sentencing/prosecutorial materials, and that expert evidence on prosecutorial/sentencing likelihoods may be admissible to fill knowledge gaps. The opinion did not purport to create a novel legal principle beyond applying established causation and review standards; its direct effect is to require further investigatory and decision-making steps by a coroner on remittal.

Disposition: The matter is remitted to another coroner for reconsideration.