HM Senior Coroner for Sefton Knowsley and St Helens v Michael Kay & Ors
[2024] EWHC 1366 (Admin)
HM Assistant Coroner for Inner London Court, Re
23 April 2024
[2024] EWHC 1085 (Admin)
High Court
A coroner's inquest into a woman's death had a mistake in the medical report. A court decided the mistake was big enough to restart the inquest to ensure a fair and accurate conclusion, especially since it affected the family's understanding of how their daughter died.
Key Facts
- •Karina Jane Brandt (Karina) was found dead at her home on July 24, 2020.
- •Her death was referred to the coroner under s.1(2) of the Coroners and Justice Act 2009.
- •A post-mortem examination and toxicology report revealed alcohol and GHB levels.
- •The initial inquest concluded with a narrative verdict of 'Death was as a result of alcohol and drug toxicity in circumstances which are unexplained'.
- •A subsequent review revealed a transcription error in the pathologist's report regarding GHB levels.
- •The corrected report indicated no evidence of GHB ingestion.
- •Karina's parents supported an application to quash the inquest and order a new one.
- •The Attorney General authorized the application.
Legal Principles
Section 13 of the Coroners Act 1988 allows the High Court to quash an inquest and order a new one if it is necessary or desirable in the interests of justice.
Coroners Act 1988, s.13(1)(b), s.13(2)(a)(i), s.13(2)(c)
The court considers factors such as fresh evidence, potential for a different conclusion, accuracy of medical evidence, and impact on the family's reputation.
R v Inner South London Coroner, ex parte Kendall [1988] 1 WLR 1186 at 1191-1192
The Divisional Court cannot amend inquest findings; it can only quash them.
HM Senior Coroner for South London v HM Assistant Coroner for South London [2022] EWHC 1388 at para.20
Outcomes
The inquest's determination and findings were quashed.
New evidence revealed a material error in the original post-mortem report, potentially leading to a different conclusion and impacting the family's perception of their daughter's death.
A further investigation and inquest under Part 1 of the Coroners and Justice Act 2009 were ordered.
It was deemed necessary or desirable in the interests of justice to rectify the inaccuracies in the initial inquest and ensure a fair and accurate account of Karina's death.
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