Case Note: R. (on the application of Bryan) v HM…

Facts

In R. (on the application of Bryan) v HM Coroner for Buckinghamshire [2024] EWHC 26 (Admin), the Claimant sought judicial review of the coroner’s conclusions in respect of the tragic death of a mother and her young daughter. The very sad circumstances of their deaths were that a mother (Ms Redmond) jumped onto a train track into the path of an oncoming train whilst holding her daughter in her arms. Both were killed instantly.

Following the inquest, the coroner returned a short-form conclusion of suicide in relation to Ms Redmond and a lengthy narrative-only conclusion in relation to the child, which included the following: “it was not possible to determine that [Ms Redmond] was not suffering from such a disease of the mind as to be incapable of distinguishing between right and wrong and was therefore likely to be legally insane.”

The Claimant, the child’s aunt, argued that the coroner erred in adopting a presumption of insanity in relation to Ms Redmond, and contended that any conclusion other than a short-form conclusion that the child was unlawfully killed was irrational.

Judgment

The claim was refused.

The Divisional Court emphasised that concepts of “presumptions” and “burdens of proof” were unsuitable to be applied to the deceased person or to interested persons involved in an inquest, for basic reasons of fairness. That was particularly the case where the person whose conduct was at issue was themselves the deceased and a subject of the inquest.

The Court held that the key questions for the coroner when addressing the issue of insanity in an inquest are:

Whether on all the available evidence, the issue of insanity was properly raised and if so, is there is sufficient evidence of insanity for it not to be withdrawn from consideration (either by the coroner or, if there was one, the jury)?
Whether, on all the relevant evidence, the correct conclusion on the balance of probabilities was that the person in question was not insane?

If it was more likely than not that the person was insane at the time of committing the act that had led to the death in question, a conclusion of unlawful killing would be unsafe and should not be reached (see paragraph 23 of the judgment).

The Divisional Court concluded that this approach was also underpinned in paragraphs 2 and 32 of the Chief Coroner’s Law Sheet No.1 on Unlawful Killing which respectively state that:

“[Maughan] means that a conclusion of unlawful killing may only be reached, following an inquest, when the Coroner or jury is satisfied on the balance of probabilities (so that it is more likely than not) that a death was caused by one of the following criminal offences: (1) murder, (2) manslaughter … and (3) infanticide."

"The conclusion of unlawful killing may not, however, be available if there is evidence that the person who carried out the act which led to death was insane at the time and therefore lacked the necessary mens rea for the offence. The test is as follows: Is the coroner (or the jury) satisfied that the person was not legally insane at the time of the killing?"

In the Divisional Court’s view, paragraph 32 did not seek to introduce a presumption of sanity. Rather, it addressed the approach to be adopted where there is evidence that the person who carried out the act which led to the death lacked the necessary mens rea for an offence of murder, manslaughter or infanticide. The Court went on to state that: “It is unlikely to be helpful to parse the evidence into discrete sections relating to the actus reus and mens rea of the offence in question, though it would not necessarily be wrong to do so if the facts of a given case justified it”.

In terms of the conclusion reached by the coroner, the Court noted that this case was detailed, sensitive and complicated. In those circumstances, the Coroner’s decision to give a narrative conclusion had been fully justified. Whilst the narrative conclusion itself had been “less than immaculately expressed”, because it had introduced a ““clunky” double negative”, the findings made by the Coroner were nonetheless reasonably clear, and the Court was satisfied that the conclusions reached were “well within the bounds of conclusions which were open to him on the available evidence”.

Comment

This judgment provides a clear roadmap for the correct approach to be adopted by coroners in inquests where there is a potential issue concerning insanity, in addition to confirming the meaning of the parts of Chief Coroner’s Law Sheet No.1 relating to insanity.

The Claimant has applied for permission to appeal. Should permission be granted, this case will be an important one for inquest practitioners to watch.

This article was written by Harriet Wakeman.