Law Report: Inquest limited to cause of death: Regina v Coroner for Western District of East Sussex, ex parte Homberg and others - Queen's Bench Divisional Court (Lord Justice Simon Brown and Mr Justice Morland), 26 January 1994

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A coroner's overriding duty to inquire 'how the deceased came by his death' did not encompass inquiry into the underlying responsibility for every circumstance which might have contributed to the death, such as, in the case of death by fire, the lack of a fire escape.

The Queen's Bench Divisional Court dismissed an application, by relatives of the deceased, for a fresh inquest into the deaths of five people who died in a fire at 11 Palmeira Avenue, Hove on 18 April 1992.

The fire had been started deliberately 'as a prank' by Trevor Carrington, who later committed suicide. But the lack of a fire escape at the premises had attracted considerable public concern.

The coroner, Dr Gooding, summoned a jury, pursuant to section 8(3)(d) of the Coroners Act 1988, on the ground that 'there is reason to suspect . . . (d) that the death occurred in circumstances the continuance or possible recurrence of which is prejudicial to the health or safety of the public or any section of the public'.

The jury returned unaminous verdicts of unlawful killing in regard to the fire victims. But the applicants sought to quash the inquisition and order a fresh inquest on the grounds, inter alia, that the coroner failed to ensure a proper investigation into where responsibility lay for the absence of a fire escape, and that his directions to the jury were inadequate.

Edward Fitzgerald and Colin Davis-Lyons (Dexter Montague & Ptnrs, Reading) for the applicants; John Samuels QC (City Solicitor) for East Sussex County Council.

LORD JUSTICE SIMON BROWN, having referred to section 11 of the 1988 Act and rules 36 and 41-43 of the Coroners Rules 1984, said it was clear that the coroner's overriding duty was to inquire 'how' the deceased came by his death. Although 'how' was to be widely interpreted, it meant 'by what means' rather than 'in what broad circumstances'. In short, the inquiry was confined to matters directly causative of death.

Mr Fitzgerald argued, by analogy with recent cases on 'lack of care' verdicts, that wherever, but for some culpable human failure, the deceased would probably have lived, the coroner should afford the jury an express opportunity to record that failure in their verdicts.

But it was one thing to recognise a verdict of 'lack of care', the essential dependency of the relationship between deceased and carer emphasising the directness and immediacy of the carer's responsibility for the death; it was quite another to incorporate within the verdict itself whatever in the way of contributory causes could ultimately found a successful civil liability claim.

The duty to inquire 'how' the deceased died did not properly encompass inquiry into the underlying responsibility for every circumstance which might have contributed to the death.

MR JUSTICE MORLAND gave a concurring judgment.