Page 35 - When Things Go Wrong

2.46 A further issue arises in relation to cases where the coroner decides that they
are unable to discharge their investigative obligations because of a claim for
public interest immunity (PII), and the coroner asks the relevant Minister to
convert the inquest into a public inquiry. There is no statutory process for such
a request and it can lead to considerable delays. Neil Sheldon QC writes:

The request in Grainger was made in November 2015 and the decision to
establish the inquiry was taken in March 2016. In Litvinenko the delay
was even longer, not least because of the intervening judicial review […].
The lesson provided by these cases, and the Manchester Arena Inquest in
which the potential problem of delay is anticipated, is that the PII nettle
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should be grasped sooner rather than later.

2.47 We have designed our proposed Special Procedure Inquest (SPI) such that it
could consider closed evidence (see paras 2.69, 2.74 and Annexe), therefore
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avoiding conversion altogether. However, in cases where – in any event – a
public inquiry is established to investigate one or more deaths, the Working
Party recommends that the inquiry, where possible, should be required to
answer the four statutory questions.
90

Investigating deaths linked systemically

2.48 A Senior Coroner who is made aware that the body of a deceased person is
within their area must as soon as practicable conduct an investigation into the
person’s death if they have reason to suspect that the deceased died a violent

88 Neil Sheldon QC, ‘Conversion of the Inquest to a Public Inquiry’ (1 Crown Office Row conference,
‘Is this too sensitive? Dealing with difficult issues in inquests and inquiries’, October 2019). Sheldon
also cites the inquest into the death of Jermaine Baker, awaiting conversion at the time the conference
paper was delivered. Conversion was announced on 13 February 2020, some eleven months after HHJ
Goldstone QC was appointed to hold the inquest. Baker was killed by armed police in December 2015.
89 See Ministry of Justice, Justice and Security Green Paper (Cm 8194, 2011), pp. 15-16.
90 We accept that this is already the case for inquiries suspended under Coroners and Justice Act, sch 1
para 3. However, this accommodates only the narrow subset of cases where the Lord Chancellor requests
the coroner to suspend the inquest on the ground that the cause of death is likely to be adequately
investigated by a statutory inquiry and a “senior judge” has been appointed as chair.
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