Page 34 - When Things Go Wrong

“inquisitorial” investigations both directed at establishing the facts of a fatal
incident.

2.44 Professor Phil Scraton highlights one of many injustices arising from the
multiple legal processes involved in investigating the Hillsborough disaster.
The original, quashed inquest was structured so that the opening hearings
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served as “a kind of Taylor [Inquiry] rerun” : “given that the coroner had
debarred evidence taken by Taylor from the inquest, it was inconsistent that
[South Yorkshire police superintendent Roger] Marshall was allowed to
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criticise the inquiry and its findings”.

2.45 The Grenfell Inquiry has also demonstrated the potential for duplication. In a
ruling following the Inquiry’s second procedural hearing, The Chair expressed
the hope that he could “minimise as far as possible the need for [the coroner]
to re-open any of the inquests and thereby to spare the relatives of those who
died the need to endure further proceedings in relation to the deaths of their
family members”. However, the four statutory questions (who the deceased
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was, and how, when and where the deceased came by his or her death), which
must be answered in every inquest, are not expressly set out in the Inquiry’s
Terms of Reference. Further, the Chair noted that he could “foresee some
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potential difficulty in making extensive and detailed findings about the
movements of each of the deceased in the period leading up to his or her death”.
“Evidence relating to the deceased” serves as the eighth and final module of
the Inquiry’s Phase II; at time of writing there is still no guarantee that this
module will enable the Coroner for London Inner West to close the inquests.

84 Scraton, supra note 2, p. 199.
85 Ibid, p. 214.
86 Sir Martin Moore-Bick, ‘Chairman’s Response to Submissions made on 21 March 2018’ (Grenfell
Tower Inquiry, 28 March 2018), para 4. In the previous paragraph, the Chair noted submissions made
by bereaved and survivor core participants stressing “the importance…of making findings of fact
sufficient to meet the requirements of an inquest which satisfies the state’s obligation under article 2 of
the European Convention on Human Rights, thereby making it unnecessary for the coroner to continue
the inquests which she has suspended” – submissions contested at the hearing by Counsel to the Inquiry.
87 Coroners and Justice Act 2009, s. 5. In an Article 2 ECHR inquest, the question of “how, when and
where” is to be read as including the purpose of ascertaining in what circumstances the deceased came
by his or her death. The Grenfell Tower Inquiry terms of reference do commit to examine the
“circumstances” surrounding the fire at Grenfell Tower on 14 June 2017, but the 72 deaths are not
referenced explicitly.

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