Bell v HM Coroner for South Yorkshire (Eastern District)

In this post, Alex Carington considers a recent unsuccessful application under s. 13 of the Coroner’s Act 1988 in light of new evidence to quash an inquest in 1992 into the death of a woman who stepped into the path of an oncoming train where an open verdict was reached.

The Facts

X had been diagnosed with schizophrenia and admitted twice into a mental heath hospital. After she was discharged, she remained an outpatient and also undertook work at the hospital as a ward aid. During this time, X developed a relationship with a student nurse working at the hospital (“B”) during which she became pregnant and ultimately underwent a termination.

X’s relationship with B ended and X went to live with her mother in a different area despite having a difficult relationship with her. She remained under community psychiatric care. In 1991, about 4 years after her last admission to a mental health hospital, X went to a train station and stepped into the path of an oncoming train. At the inquest into her death in 1992, the corner recorded an open verdict.

In 1999, the mental health hospital, at which X had been admitted and where she had developed her relationship with B, closed due to a systemic failure to prevent unprofessional and degrading practices towards patients. In that same year, X’s mother told the claimant, X’s brother, about X’s relationship with B. The claimant reported the matter to the police, but B was not prosecuted, following both an investigation and a review which concluded it was not in the public interest to do so.

The claimant contacted the defendant coroner asking for the original inquest to be quashed on the basis that there was fresh evidence as to X’s state of mind at the time of her death, which included:

  1. Her inappropriate relationship with B, which led to a termination.
  2. The hospital’s knowledge of this relationship and their failure to disclose it.
  3. Evidence of inadequate management which allowed the relationship to happen.

The Coroner declined, having considered that this was not cogent new evidence as to X’s state of mind on the day of her death, and the 30 year delay meant the original documentation had been destroyed and memories of any witnesses would no longer be reliable.

The claimant applied under s. 13 of the Coroners Act 1988, which allows the court to quash an inquest and order an investigation by the coroner in certain circumstances, including where there has been the discovery of new facts or evidence.

The Judgment

The single question to consider when deciding whether to order a new inquest was whether it was in the interests of justice. Interests of justice was undefined, but the function of an inquest is to seek out and record as many facts as possible concerning an individual’s death as public interest requires. New evidence as to how an individual met their death would be in the interests of justice. It was also not essential to show that a new verdict would necessarily be reached at any new inquest.

However, the new evidence had to be cogent evidence. It could not mean “any” evidence. In this instance, the new evidence concerned events that occurred roughly 3 years before X’s death, and there was no evidence how, if at all, those events affected X on the day of her death. The family’s observations on X’s relationship with B and the impact of her termination were speculation. Accordingly, the lack of new cogent evidence was fatal to the application.


Whilst s. 13 of the Coroners Act 1988 confers a broad power to order a new investigation into a death in certain circumstances, this judgment makes clear that in cases where there is new evidence, that evidence will need to be cogent to justify a new investigation. This is even more relevant in cases where there has been a long passage of time since any initial inquest, where the quality of the evidence heard on that occasion will also have diminished.

Whilst there was clear evidence as to X’s relationship with B at the time of the initial inquest, which was unknown to the coroner, the passing of 3 years between that relationship and X’s death meant it was difficult to establish any link between those events and their impact on the state of mind at the time of her death. It also appears that the continuing impact of those events on X, if any, was unknown and was a simply matter of speculation by the family.

One could envisage a different decision being reached if X’s death had occurred on a significant anniversary (such as the date of her termination), and if there had been some new evidence as to a continuing impact caused by those events despite the passage of time. However, it does not appear such evidence existed here.

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