Page 42 - When Things Go Wrong

prolonged examination of documents or accounts or any scientific or local
investigation which cannot conveniently be undertaken with a jury. 113 Neither
jury nor assessors would be used in cases where closed evidence may be called
and relied on.

Oversight and administration

2.75 The Chief Coroner could invoke the SPI in the course of a standard inquest
should further information come to light (for example, of other cases involving
similar systemic issues).

2.76 The Chief Coroner would maintain an oversight and advisory role throughout
the process, including during the preliminary hearings in order to monitor the
timetable and to ensure family participation, without encroaching on the
independence of the judge or Senior Coroner.

2.77 The cost of the investigation and inquest(s) should be paid from central funds
(see paras 2.81-2.83 below). The Chief Coroner, or following the decision to
establish an SPI, the judge or Senior Coroner appointed to conduct it, could
draw upon the advice of the Central Inquiries Unit as to its management.

Related criminal investigations

2.78 The not guilty verdict in the 2019 criminal trial of Chief Superintendent David
Duckenfield, coming after a conclusion of unlawful killing in the 2014-16
Hillsborough inquests, highlighted the injustice felt when criminal
investigations follow (and diverge from) inquest conclusions. In an article
reflecting on that case, David Conn argued that “the perverse and wasteful
separation between public inquiry, criminal prosecution and inquests should

113 See Senior Courts Act 1981 s. 69. The Working Party considered whether the SPI should include the
option for panellists to sit alongside the judge or Senior Coroner, as in the Inquiries Act 2005 s. 3. The
benefits of panellists in respect of representation were noted. However, given that the coroner holds a
judicial office which must be discharged without consultation, panellists could only perform a limited
advisory role under the SPI. It is hoped that sufficient representation and diversity of the tribunal could
be secured through (in the majority of cases) the use of a jury, and through a transparent and rigorous
appointments process.

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