On 11 September 2006, an employee of Need a Skip Ltd was killed when a loader driven by another employee reversed over him on the company’s premises. The coroner opened an inquest on 15 September 2006 but adjourned it immediately, pending the outcome of investigations by the police and the Health and Safety Executive. In February 2009, the CPS decided not to bring any charges of manslaughter, and informed the coroner of their decision. The coroner made a number of decisions regarding disclosure, the scope of the inquest, and directions to the jury. The company directors applied for judicial review of the decisions made by the coroner.

The directors challenged the coroner’s decisions about the evidence that was to be disclosed to the jury, as well as the scope of the evidence to be called, and the coroner’s rejection of their application for an adjournment. They also submitted that there was apparent bias on the part of the coroner on the following grounds:  

  1. In the circumstances of this case, no verdict of unlawful killing could properly be left to the jury. Also, the coroner was wrong to seek to consider evidence about alleged breaches of Health and Safety Regulations in the fi ve years prior to the incident.  
  2. The coroner was wrong to justify the scope of the inquiry on the ground that it would enable the jury to consider returning a narrative verdict or because of the possible need to refer the matter to the relevant authorities under the Coroners Rules 1984. 
  3. The coroner wrongfully refused to disclose evidence and then to adjourn the inquest to enable the directors and their legal representatives to deal with this shortly before the hearing of the resumed inquest was to commence.  

The coroner’s defence was that, in this type of inquest, the coroner’s inquiry might go beyond what is needed for a narrow verdict of “by what means” the deceased came to his death. It could include the causes of the incident, including questions of system, training, methods of work, and safety equipment if causally relevant. In this case, the coroner identifi ed the system of work as a potentially relevant causative factor in the death and was entitled to call evidence regarding it.  

The Administrative Court held that the coroner erred in the approach he used to determine the scope of the inquiry, the evidence to be adduced and in his approach to disclosure. As to potential bias, the court asked whether there was a real danger that the coroner unfairly regarded with disfavour the case of the claimants when deciding the scope of the evidence to be adduced at the inquest so that he would, albeit unconsciously, weigh the competing contentions and decide the merits unfairly. It concluded that it was right that the resumed hearing of the inquest take place before a different coroner or the deputy coroner.

In R (on the application of Butler v HM Coroner for the Black Country District [2010]