Page 41 - When Things Go Wrong

2.70 The SPI should determine answers to the four statutory questions, 105 the
medical cause of death and a conclusion as to the death. In a type II SPI, scope
may well include evidence on other deaths, and on episodes of near-death. 106

2.71 Findings of fact should be neutral (conferring no civil nor criminal liability)
107
but where appropriate, “judgmental”, as in Article 2 ECHR inquests. 108 In a
departure from the current position, 109 findings would be admissible (although
not binding) in civil proceedings. 110

2.72 In addition, the SPI should formulate recommendations to prevent future
deaths, 111 hearing further evidence if necessary. Recommendations could be
wider than permitted under the current regime, extending to specific actions to
be taken by addressees. 112 Formulation of recommendations would be for the
judge or Senior Coroner alone, although they may draw on narrative
conclusions from the jury.

Composition of tribunal

2.73 Final hearings should be conducted by the judge or Senior Coroner, either
alone, with a jury or with two lay assessors (at the discretion of the judge or
Senior Coroner). The mandatory and discretionary provisions on empanelling
a jury under Section 7 of the 2009 Act would apply.

2.74 A jury would be the usual option; but assessors could be used, for example,
where the judge or Senior Coroner is of the opinion that the SPI requires a

105 Coroners and Justice Act 2009, s. 5.
106 See R (L) v Secretary of State for Justice [2009] 1 A.C. 588.
107 Coroners and Justice Act 2009, s. 10(2).
108 See ‘Chief Coroner’s Guidance No.17: Conclusions’, 2016, paras 34, 51-52.
109 i.e. an exception to the rule in Hollington v Hewthorn (1943) K.B. 587.
110 The Working Party agrees that the findings of all inquests should be admissible in civil proceedings.
This proposal, however, lies beyond our terms of reference.
111 Coroners and Justice Act 2009, sch 5 para 7.
112 See ‘Chief Coroner’s Guidance No. 5: Reports to Prevent Future Deaths’, 2016, para 24.
34