Key takeaways
Judicial review challenges coroners’ decisions
Courts assess whether verdicts comply with legal standards.
Unlawful killing requires strong evidential basis
Verdicts hinge on clear proof of criminal responsibility.
Early advice helps manage complex proceedings
Specialist guidance reduces risk of costly legal disputes.
Judicial review of unlawful killing: Legal considerations
Sean Glaister & another -v- HM Assistant Coroner for North Wales (East and Central)
In January 2025, Judge Fordham upheld an inquest jury’s unanimous conclusion that Scout leaders, Sean Glaister and Mary Carr were responsible for the unlawful killing of 16-year-old Ben Leonard (“the deceased”), who died after falling from a cliff during a Scout expedition in North Wales.
Background
On 16 August 2018, the deceased became separated from his group during a 3-hour unplanned hike on the Great Orme near Llandudno. He fell approximately 60 meters from a ledge, sustaining fatal head injuries.
An inquest held in February 2024, concluded that his death was by unlawful killing, attributing responsibility to Explorer Scout Leader, Sean Glaister and Assistant Scout Leader, Mary Carr. The jury also found that his death was contributed to by the neglect of the Scout Association. The inquest revealed that the group lacked proper planning and risk assessments for the hike.
The Assistant Coroner for North Wales issued a Prevention of Future Deaths (PFD) report, comprising 39 different areas of concern, including a concern that there is no robust regulator who independently and periodically audits and inspects the systems, processes and training of The Scouts Association or the granting of permits for adventurous activities.
More on Prevention of Future Deaths reports can be found here.
Judicial review
Following the inquest, the claimants (Glaister and Carr) sought a judicial review to overturn the unlawful killing verdict. Fordham J upheld the jury’s conclusion, emphasising the importance of thorough and public scrutiny of the facts, noting that an “inquest is entitled to get to the bottom of the facts” and the “need for public confidence in an inquest being able to lead to clear findings on the balance of probabilities”.
However, Fordham J identified significant deficiencies in the Coroner’s handling of the inquest and in his decision making. The jury’s findings were not invalidated, but the Coroner’s potential misdirection of the jury necessitated a revaluation of the conclusions drawn in the inquest.
Key considerations
In reaching his judgment, Fordham J considered the following:
The lawfulness of the Coroner’s Ruling
The Coroner had to decide whether, on a possible view of the facts, there was evidence on which the jury could properly come to the conclusion that the deceased was unlawfully killed.
Counsel for the claimants argued that there was nothing which a properly directed jury could properly find satisfied each of the six elements of gross negligence manslaughter as outlined in R -v- Broughton [2020] and therefore, the Coroner acted unlawfully or unfairly in deciding to leave the conclusion of unlawful killing to the jury.
Fordham J disagreed. Whilst he considered that the Coroner’s list of potential breaches to meet the elements of the legal test for gross negligence manslaughter was overly inclusive, the Coroner’s reasoning in the ruling expressed satisfaction that each of the potential breaches in the identified list could meet the six elements.
The lawfulness of the Directions
Counsel for the claimants submitted that the list of potential breaches were “signalling” by the Coroner to the jury that certain facts must be accepted to be breaches, when these were matters for the jury to decide, without influence from the Coroner.
Fordham J was unable to accept this argument and found that the directions were not flawed in a material way. The Coroner made clear that it was the jury’s function to decide the facts and to decide what was a breach of duty to take “reasonable care”. He was not answering the question for them and therefore there was no risk of confusing the jury, or bringing in a wrong conclusion because of a misunderstanding.
Whether the Coroner’s summing up was so deficient as to render unsafe the jury’s conclusions
Counsel for the claimants argued that there was a material deficiency in the way in which the Coroner summed up the witness evidence, with Counsel for the claimants submitting that the Coroner repeated or amplified a piece of expert evidence which was materially unfair or unlawfully prejudicial.
Fordham J was unable to accept these submissions, adopting the position of Collins J in R (Anderson) -v- HM Coroner for Inner Greater London [2004], that a summing-up should not be subjected to a close analysis or that it does not necessarily follow that the absence of a particular form of words or particular directions will necessarily be fatal.
Impact
This judgment confirms that coroners have the discretion to allow a jury to return a conclusion of unlawful killing in cases where there is evidence of gross negligence manslaughter. It also serves as an important reminder that inquests are not only fact-finding exercises, but can also play an important role in determining the degree of responsibility for a death.
You can read Fordham J’s judgment in full here.
