“(1) An inquest is a fact finding inquiry conducted by a coroner, with or without a jury, to establish reliable answers to four important but limited factual questions. The first of these relates to the identity of the deceased, the second to the place of his death, the third to the time of death. In most cases these questions are not hard to answer but in a minority of cases the answer may be problematical. The fourth question, and that to which evidence and inquiry are most often and most closely directed, relates to how the deceased came by his death. Rule 36 requires that the proceedings and evidence shall be directed solely to ascertaining these matters and forbids any expression of opinion on any other matter. (2) Both in Section 11 (5) (b) (ii) of the Act of 1988 and in Rule 36 (1) (b) of the Rules of 1984, “how” is to be understood as meaning “by what means”
“That, of course, was a Section 8 (3) (a) case, but its adaptability to a Section 8 (3) (d) context is obvious. It is, in short, for the individual coroner to recognise and resolve the tension existing between Sections 8 (3) and 11 (5) (b) of the 1988 Act and Rule 36. The inquiry is always bound to stretch wider than strictly required for the purposes of a verdict. How much wider is pre-eminently a matter for the coroner whose rulings upon the question will only exceptionally be susceptible to judicial review.”
“This is not to detract from the importance of the role of the inquest in particular where someone dies in custody, as here, an inquest can provide the family with the only opportunity they will have of ascertaining what happened. In addition, as (Counsel) contends, an inquest verdict can have a significant part to play in avoiding repetition of inappropriate conduct and in encouraging beneficial change.”
“Only one change is in our opinion needed: to interpret “how” in Section 11 (5) (b) (ii) of the Act and Rule 36 (1) (b) of the rules in the broader sense previously rejected, namely as meaning not simply “by what means” but “by what means and in what circumstances”.”
“It is clear that the scope of a Jamieson inquest is not limited to the last link in the chain of causation…In Dallaglio’s case Sir Thomas Bingham stated that it was for the coroner to decide on the particular facts of the case at what point “the chain of causation becomes too remote to form part of his investigation”.”
“I further agree with Lord Phillips PSC that in practice the only real difference between a Jamieson inquest… and a Middleton inquest is likely to be with regard to its verdict and findings, rather than its inquisitorial scope. As I pointed out in Hurst[2007] 2AC189 , paras 27, 51, the scope of the inquiry is essentially a matter for the coroner. Such indeed had been eloquently recognised in Jamieson[1995] QB 1 itself in the court’s judgment given there by Sir Thomas Bingham MR (at paragraph 14 of the Court of Appeal’s general conclusions, page 26)…”
“ Although as I recognised in Hurst[2007] 2AC189 , para 51, the coroner may sometimes choose to widen the scope of the inquiry if he recognises that Article 2 conclusions of fact (and thus a Middleton verdict and findings) are required, more probably (as Lord Hope envisages at para 95 of his judgment) the coroner is likely to decide the scope of enquiry with a view rather to the exercise of his rule 43 power to make a written report to a responsible authority aimed at avoiding similar fatalities in the future”
“I am fully alive to the existence of a current of opinion strongly flowing in favour of openness and disclosure. I am also, however, mindful of the fundamental public interesting in ensuring that those responsible for maintaining law and order are themselves un-corrupt, law abiding, honest and responsible. I do not myself find the points made by Mr Cartwright in his affidavit to be unconvincing, unrealistic or suggestive of self-interested special pleading. In very many cases where an investigating officer is appointed, there must be real prospect of civil, criminal or disciplinary proceedings. I have no difficulty in accepting the need for investigating officers to feel free to report on professional colleagues or members of the public without the apprehension that their opinions may become known to such persons. I can readily accept that the prospect of disclosure in other than unusual circumstances would have an undesirably inhibiting effect on investigating officers reports. I would therefore hold that the reports of investigating officers made in circumstances such as these form a class which is entitled to public interest immunity. That does not, of course, shut out the plaintiff if he is able to satisfy the judge, applying the familiar tests, that, on the backs of this case, the public interest in disclosure of the contents of these reports or any part of them, outweighs the public interest in preserving the confidentiality of these reports. That is a matter for the trial judge and it is a judgment which he will be very well fitted to make”
“…However, I need to focus upon the distinctive nature of a coroner’s inquest, which differs in fundamental respects from that of civil litigation of the kind which has been considered in the recent judicial observations to which I have referred. As with disclosure of documents, so with the witness summons directed to third parties, it is possible in the context of civil litigation to define both relevance and (to an extent) “necessity” by reference to the statements of case, where the issues are identified. There is nothing closely comparable in relation to a coroner’s inquest, which is inquisitorial in nature…”