On the 17 November 2010, a Judicial Review case, R (on the Application of McLeish) v Her Majesty's Coroner for the Northern District of Greater London (2010) was heard. The case concerned the actions of the defendant coroner. The claimant (M) was the mother of the deceased and sought declarations that the coroner had:

breached common law principles and the Coroner’s Rules 1984 rule 57 (which requires a coroner, on the payment of a fee, to provide copies to any interested party of the post mortem report, notes of evidence and documents put in evidence) ; and violated M’s rights under article 8 of the European Convention on Human Rights (the right to respect for private and family life).


Following the death of M’s son (X) an inquest was opened. M informed the coroner that she wanted to know the answer to the fundamental question of “how” he had died. The inquest was adjourned following which a coroner sent the death certificate stating that the precise medical cause of death was not yet ascertained. M was reassured by the coroner that a decision would be reached and that he would keep M updated about developments. X’s body was buried.

A toxicology report was undertaken which stated that no drugs had been detected in X’s body. M contacted the coroner and was informed that a post-mortem report had not yet been obtained and the coroner would contact M with developments. X’s cause of death remained unascertained. However, no indication was given to M that the post-mortem report had been received or that the investigation had ended. Almost three months after M’s last conversation with the coroner she wrote to him asking for an update. She did not receive a response. Three months later M telephoned the coroner and, upon her request the reports were sent to her. She subsequently requested blood samples previously taken but was informed that they had been destroyed. M complained. An inquest was later held by a different coroner who reached an open verdict.


  • M submitted that the delay prevented proper further examination of material including histology.  

The coroner contended that:  

  • M could have asked for further samples and could have applied for a second post-mortem without having seen a report from the first post-mortem and the toxicology report;
  • no formal request was made by M for copies of the reports; and
  • no fee was paid by M when she requested the copies.


The court decided that:  

  • It should have been clear to the coroner that M wanted to be informed of the reports and their contents. There was a failure by the defendant coroner to act according to the assurances he had given M. If M had been told of how X had died she would have able to decide whether samples were to be the subject of histological examination. The opportunity was lost when the samples were destroyed. Whilst the court found that M could have asked for samples earlier this ignored the reality when dealing with ordinary members of the public who are of limited means and who relied on the coroner’s inquest to help out on their behalf. It was also decided that it was unrealistic to expect M, a member of the public, to involve herself in the personal expense of applying for a second post -mortem when she had no idea of what the first post-mortem and toxicology had found. The coroner’s failure to give M an opportunity was a failure in that it made one of the principle purposes of an inquest, namely, establishing the cause of death, impossible.
  • There was an informal application for a copy of the report. There was an application but no fee was demanded from M. The court found that M would not have known that she had to pay a fee. There had therefore been a failure to comply with rule 57.
  • M’s contention that there had been a violation of Article 8 was refused. It was held that there could not be a right to know a cause of death when in so many cases that cause could not be established.

M was granted a declaration that the coroner had breached the common law and Rule 57.

This case is a strong indication that the courts are supportive of the position of families and are keen to ensure that ordinary members of the public, who are of limited means and rely on coroner’s inquests to help out on their behalf, are treated in a fair and equitable manner.