Page 37 - When Things Go Wrong

that the SPI is adopted for “specified deaths”. The specified deaths to be
investigated are:

i. multiple fatalities, i.e. two or more deaths occurring in
circumstances giving rise to serious public concern or for other
good reason (“type I”); and
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ii. any death which a coroner has reason to suspect requires
investigation and which, by reference to another death or deaths,
may give rise to issues of systemic failure (“type II”). The issues
may arise either:
a. from an inquest or inquests already held or;
b. from a death or deaths (including deaths in other coroner
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jurisdictions) in which no inquest has yet been held.

2.52 The SPI would not be able to overturn any findings of facts, answers to the
four statutory questions or conclusion of any other completed inquest. The SPI
could only consider evidence in relation to a death forming the subject of
another completed inquest if a potential issue of a similar systematic failure
arose, and evidence from the earlier inquest were considered by the SPI judge
or Senior Coroner to be relevant to the issues addressed by the SPI.

2.53 The SPI could not ask the High Court to overturn the conclusions of another
completed inquest. If, as a result of the SPI, it was thought that the previous
inquest should be revisited by the High Court, the Attorney General could
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apply to have the inquest quashed in the normal way.

2.54 The scope of the SPI would be a matter for the judge or Senior Coroner when
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setting its terms of reference.

95 Obvious examples of type I multiple fatality cases include deaths from an aircraft, helicopter or train
crash, deaths of children in a school bus incident, and multiple deaths from a single terrorism incident.
96 One or more transfers would take place under existing provisions in Coroners and Justice Act 2009
ss. 2-3 so that the inquests may be held together.
97 Coroners Act 1988, s. 13.
98 See Coroner for the Birmingham Inquests (1974) v Hambleton & Ors [2018] EWCA Civ 2081 [48].
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