In the recent court decision in Dowler v Hornsey Coroners Court (2009), the Administrative Court came to the conclusion that on the facts it was necessary, desirable and appropriate for that particular inquest to be heard by a different coroner.
Under section 13 of the Coroners Act 1988, the court may exercise its discretion to order a new inquest to be heard by a different coroner where because of fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry or the discovery of new evidence, it is in the interests of justice that another inquest should be held.
In this particular case, the coroner concluded that on the balance of probabilities, neglect had contributed towards the death and a failure to carry out a medical test on an urgent basis constituted a serious failure to provide basic medical care. The clinician involved had not been notified of the inquest or called to give evidence. The court found that the coroner had demonstrated bias in his approach by making his conclusions based upon the clinician’s conduct without giving the clinician the opportunity to deal with the issues and present their version of events.
This case makes clear the need for the coroner to ensure that all relevant witnesses are called to give evidence before reaching any conclusion that may be based upon their actions as described by other witnesses.