Case No. CO/4995/2007 
Neutral Citation Number: [2008] EWHC 1293 (Admin)
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION 
THE ADMINISTRATIVE COURT 
Royal Courts of Justice 
Strand
London WC2A 2LL 

Date: Thursday, 10th April 2008
 
B e f o r e: 

MR JUSTICE CRANSTON

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Between: 
THE QUEEN ON THE APPLICATION OF LAWRANCE 
Claimant

v 

HM CORONER FOR WEST SOMERSET 
Defendant 
 
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The Claimant appeared as a litigant in person
Ms Jerome (instructed by HM Coroner West Somerset) appeared on behalf of the Defendant 
 
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J U D G M E N T 

1.	MR JUSTICE CRANSTON:  Miss Christine Lawrance is the claimant in this case.  She has a deep sense of grievance about the circumstances surrounding the death of her father in 1999 and what happened subsequent to his death.  In particular, she has instituted this judicial review to compel the coroner to conduct an inquest in relation to that death.  She acted in person today and has explained to me that she does not have the resources to seek legal advice or assistance, although over the years since her father's death she has sought advice from various people. 
2.	She has prepared a number of documents for this hearing, and in particular a seven page summary of her case.  She has also supplemented that today in her address to me.  She tells me in the document about the background to her father's condition in the years leading up to his death.  She was caring for her father, who had become blind and also had mental problems, and she tells me that she eventually obtained a protection order in relation to her father's affairs.  In addition, she tells me that a social worker was assigned by her local authority to provide assistance, but he was, in her view, unhelpful or worse.  She also tells me about the general practice at the Highbridge Medical Centre who were responsible for her father and she told me about one particular doctor in that practice, Dr Trow (now deceased) who she says, at least with hindsight, was, in her view, and to put it no higher, incompetent.  She does have a document in her bundle where Dr Trow claims to be a member of the Royal College of General Practitioners and there is a letter from that Royal College saying that in fact Dr Trow was not a member.  But I can make no findings about Dr Trow today.
3.	In the document that Ms Lawrance has prepared for today, she tells me about the struggle she had in terms of looking after her father.  Because of his medical condition he was not able to take painkillers which made it much more difficult to care for him.  She also tells me that in fact she did not acquire the medical assistance which was necessary to deal with her father's problems.  She does say, however, that her father was only suffering from sciatica and arthritis, although the arthritis in some respects was not insignificant.
4.	As I say, her father died in 1999.  Ms Lawrance found her father dead in his sleep and the doctor, Dr Edwards, gave the death certificate which is marked "myocardial infarction, ischemic heart disease".  It is then certified by Dr Edwards.  As I understand it, ischemic heart disease is commonly known as a heart attack, which is a not uncommon form of death in our society.
5.	Ms Lawrance tells me that she approached the police because of her concerns with the certified cause of death.  The death was on 8th July on a Thursday and she saw the police the following Tuesday at 6.30 pm.  They told her that it was a civil matter.  She now says with hindsight that she wishes she had gone back to talk to the police more about the matter the following morning.  She spoke to the vicar about what happened and the vicar said that, given her concerns, the funeral might have to be cancelled.  In any event the funeral was held on Friday 16th.
6.	The point, for present purposes, is that at this stage the coroner was not involved.  That is relevant to section 8 of the Coroners Act 1988, which I shall come to shortly.
7.	Ms Lawrance took me to an email which seems to come from Dr Trow and which, in as much as it can be deciphered, might suggest inconsistencies with the death certificate.  In essence, Ms Lawrance's case is that her father did not die for the reasons set out in the death certificate but because of the incompetent ‑‑ in fact as she puts it, grossly negligent ‑‑ treatment of her father in the previous two years prior to his death.
8.	The coroner was approached by Ms Lawrance in 1999 but the first correspondence we seem to have in relation to an inquest is a letter that Ms Lawrance sent in June 2004 setting out her concerns and asking for one.  The coroner replied on 29th June that, having studied the contents of the letter and having reviewed an earlier conclusion, he stood by his earlier decision not to take the matter any further.  There are subsequent letters from the coroner where the coroner maintains that position.  I should say that the letter that the coroner sent in August 1999, about a month after the funeral, was to the effect that he had made enquiries, that Ms Lawrance's father's death had not been reported to him by the doctor who had certified the death and that, in those circumstances, and having regard to the fact that her father had now been cremated, it would be impractical to carry out a post‑mortem.  The coroner pointed out that any complaints about the general practitioner should be made to the Family Practitioners' Committee.
9.	I explained to Ms Lawrance at the outset of this application that the law in this matter means that my role is very limited.  Section 8 of the Coroners Act provides that a coroner, when informed that the body of a deceased is lying within his district and there is reasonable cause to suspect that the deceased has died of a violent or unnatural death, can hold an inquest.  That section, of course, does not apply in this case because by the time the coroner was involved, Ms Lawrance's father had been cremated.
10.	Section 15 of the Act provides that where the coroner has reason to believe that a death has occurred in his district in circumstances such that an inquest ought to be held, he may report to the Secretary of State who, if he (the Secretary of State) considers it desirable to do so, can direct that an inquest be held.  I should say for the sake of completeness that there is a separate procedure under section 13 of the Act whereby an application could be made to the Attorney General, who can refer the matter to the High Court.  In this case Ms Lawrance wrote to the Attorney General but, because of the need to fund any matter that the Attorney referred to the High Court, Ms Lawrance decided not to proceed along that particular avenue.
11.	The test that I have to apply in considering whether the coroner has acted unlawfully under section 15 in not referring the matter to the Secretary of State is that set out in the decision Canning v Her Majesty's Coroner for the County of Northampton [2006] EWCA Civ 1225.  In that decision, Carnwath LJ, with whom the other Lord Justices agreed, said the coroner's decision (and this is in relation to section 8, but the same principle applies to section 15) "can only be impugned on Wednesbury grounds, in other words for irrationality or illegality" (paragraph 3).  There is a reference there to the other leading case in this area where Simon Browne LJ laid down that approach.  That is the case R (Touche) v Inner London North Coroner [2001] 1 QB 303.
12.	In my view, I cannot regard the coroner's decision not to take this matter on as Wednesbury unreasonable.  As I explained to Ms Lawrance, that test is a very demanding test because it means that I have to consider that no reasonable coroner could have come to this conclusion.  I cannot do that.  There are a number of factors which bear on this.  The first is the age of Ms Lawrance's father when he died ‑‑ he was 94 ‑‑ and the cause of death which was given, which was a heart attack.  As I said before, this is a common cause of death in our society.  But, most importantly, Ms Lawrance has not produced evidence in support of her contention of gross medical negligence leading to her father's death.  She explained to me that because of lack of funding she has not been able to do that, although she has gathered together a certain amount of evidence.  But there is no independent evidence, as it were, which I can use to say that the decision of the coroner is unreasonable in the way I have described.
13.	In addition, even if I were to order an inquest, it would not address the issue which Ms Lawrance is concerned with, namely the circumstances in the two years prior to her father's death.  Under Rule 36 of the 1984 Coroners Rules, a coroner can only decide who the deceased was and how, where and when the deceased came about his death.  In my view, that would not be wide enough to deal with the matters which Ms Lawrance wants canvassed.  There are alternative remedies open to her.  There is the possibility of civil action which was mentioned by the police all those years ago.  There are, of course, enormous problems with that now given the limitation period.  There is the second possibility of section 13 of the Act, in other words the Attorney General route.  Again there are difficulties with that.  In theory there are other possibilities involved in taking the matter further.  I do have to have regard to them in terms of judicial review even if I were to decide, which I do not, that it was Wednesbury unreasonable for the coroner to act in the way he did.  
14.	The other difficulty facing Ms Lawrance is time.  Normally judicial review proceedings must be started within three months after the grounds for making a claim first arise.  I have already indicated that the coroner refused to take the matter forward in 2004, so even if on substantive grounds it were possible for me to decide that the actions of the coroner were unlawful in public law terms, there would be this obstacle.
15.	I sympathise with Ms Lawrance.  Those are easy words for me to say.  She obviously was devoted to her father.  She over many years cared for both her parents, and I understand that she had to give up employment to do that.  Nothing I say can in any way relieve that deep sadness, loss and injustice that she feels.  Nonetheless I must refuse permission in this case.  
16.	Thank you very much.
17.	MS JEROME:  My Lord, I assume there will be no order for costs.  The coroner is not pressing for it.
18.	MR JUSTICE CRANSTON:  No.