Consideration of when independent expert evidence is required at an Inquest

Introduction

An inquest is a fact-finding inquiry held to determine, who, when, where and a how person has come about their death. As outlined in the Chief Coroner’s Law Sheet No.5, the coroner has a broad discretion in deciding which witnesses to call, and this broad discretion extends to the calling of independent expert evidence.

Legal Framework and Relevant Case Law

The Chief Coroner’s Law Sheet No.5 highlights that: 

"there is no principle that independent expert evidence is always required in order to render an inquest an effective investigation for the purposes of Article 2 of the European Convention of Human Rights (ECHR)."

Given this, this an area of law which can be guided by case law.

Chambers -v- HM Coroner for Preston and West Lancashire [2015] EWHC 31

At the inquest into the death of a prisoner who had been found suspended by ligature in his cell, the coroner determined that the inquiry was sufficient and did not require independent expert evidence. The deceased’s daughter sought a further inquest and independent expert evidence from a psychiatrist to be obtained on the basis that there was insufficient inquiry into the extent to which the prison service discharged their duty of care towards the deceased. 

The court ruled that independent expert evidence from a psychiatrist does not need to be called in every case of prison suicide, emphasising that;

"each case had to be determined on its own facts. To suggest otherwise would be to fetter the discretion of the coroner. It is long established law and practice that the coroner has a wide discretion which witnesses to call."

R (Takoushis) -v- Inner North London Coroner [2006] 1 WLR 461

This case involved an inquest for a schizophrenic individual who was able to leave A&E before being seen by a doctor. The coroner refused the family’s application to adjourn the inquest to obtain expert evidence with the coroner concluding that there was no neglect before hearing all the evidence and called only a limited number of witnesses.

The Court of Appeal found that the coroner had not conducted a full or fair investigation into the hospital’s system and ordered a new inquest to investigate why the deceased was able to leave A&E before seeing a doctor. At the new inquest the question of whether to call expert evidence was left to the discretion of the new coroner. 

Sir Anthony Clarke MR stated that:

"if an interested person wished the coroner to call expert evidence that person may put the substance of the evidence before the coroner so that the coroner may be able to decide whether or not it is appropriate"

R (LePage) -v- HM Assistant Deputy Coroner for Inner South London [2012] EWHC 1485

In this case a woman was stopped and searched by police, cocaine was found on her person and she was subsequently arrested. Whilst in police custody, she collapsed and died. The postmortem examination revealed she had died from cardiorespiratory failure and acute cocaine toxicity. The coroner decided not to call medical expert evidence and instructed the jury to return a short-form conclusion of accidental death. 

The mother of the deceased applied for a judicial review on the grounds that the coroner had erred in not calling a forensic pathologist whose report, she had obtained, suggested that restraint and search by the police may have caused or contributed to the death. 

It was held that the coroner was justified in not calling expert evidence as it was found that the coroner already had ample medical evidence that the restraint had played no part in the deceased death. Again, it was reiterated that the coroner has a power, not a duty, to call independent expert evidence and the court would only intervene if the decision to not call a witness was unreasonable under Wednesbury principles.

Ketcher’s Application for Judicial Review [2019] NIQB 4, 2019 WL 01100391

A key principle derived from this case is that the coroner is not obligated to commission expert evidence merely because it is requested by an interested party. The judgment makes clear that expert evidence should only be obtained if it materially advances the investigation. In instances where the cause of death can be established through available factual and medical evidence, the coroner is justified in declining further expert input, even if its absence leaves some questions unanswered. This approach balances the coroner’s duty to conduct thorough investigations with the need to avoid unnecessary delays, costs, or over-complication of the process.

The court also reaffirmed that judicial review is available as a safeguard against decisions to exclude expert evidence that are unreasonable or procedurally unfair. However, as demonstrated in this case, such challenges face a high threshold. 

R (on application of Smith) -v- HM Assistant Coroner for North West Wales [2020] EWHC 781 (admin)

This case involved the death of a 27-year-old female who had developed psychosis in depression and was visited regularly by a community mental health team but was later found to have hanged herself. During the Pre-Inquest Review Hearing the coroner decided that Article 2 was engaged and appointed an independent expert psychiatrist.

The psychiatrist concluded that the deceased death was entirely preventable if she had been seen by a psychiatrist and prescribed medication at an earlier stage. However, at the inquest, no other witnesses supported this opinion. 

The Divisional Court held that it was: 

"for the coroner to decide what conclusions to draw. She was not bound to accept what the expert had said in his initial report, and she was not bound to accept his evidence even if it had stood alone. She had done a good job of exploring all the evidence and her conclusion was rational and securely based."

This case reaffirmed the coroner’s independence in drawing conclusions, even when expert evidence is presented. While an independent expert may provide valuable insights, the coroner is not bound to accept the expert’s conclusions, particularly if they are not supported by other evidence.

The judgment emphasised that it is the coroner’s role to assess the totality of the evidence presented at the inquest. Even when an expert is instructed, their opinion is one piece of the evidential puzzle. The coroner must evaluate how the expert’s testimony aligns with other evidence, and conflicting views do not oblige the coroner to prioritise the expert’s findings.

Conclusion 

As there is no principle requiring independent expert evidence to be called at inquests, case law demonstrates that coroners have significant discretion in determining whether such evidence is necessary to ensure a full and fair investigation. The seminal case of Jamieson established that a coroner’s role is to ascertain the facts surrounding a death, rather than to determine issues of civil or criminal liability, and this purpose guides their decision-making on whether expert evidence is needed. This discretion allows coroners to tailor their approach to the specific circumstances of each case, ensuring proportionality and avoiding unnecessary delays or expense.

While independent expert evidence can be vital in shedding light on complex medical, scientific, or technical issues, it is not an automatic requirement for achieving a fair and effective outcome. The coroner retains the ultimate responsibility for weighing all the evidence, guided but not bound by expert opinion. 

Ultimately, the wide discretion afforded to coroners reflects their critical role in balancing thorough investigation with practical considerations. By carefully assessing the necessity and value of expert input on a case-by-case basis, coroners can ensure that inquests fulfil their statutory purpose - to investigate the circumstances of a death and provide clarity, while remaining focused, proportionate, and fair to all parties involved.

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