Ernest Andrew Brown v HM Coroner for the County of Norfolk v Chief Coroner of Norfolk Constabulary 
The decision of Lord Justice Pitchford and His Honour Judge Peter Thornton QC (Chief Coroner for England and Wales) in this successful application to quash the inquest held on 15 September 2011 into the death of Joanne Foreman and to hold a fresh inquest, raises serious questions about the reliance of the Coroner on the interested party who investigates a death, such as the Police Force or the Ministry of Defence, and the resulting relationship between the two. It also highlights the need for bereaved families to be put at the heart of the coronial process and not to be treated in such a way that they feel marginalised and concerned that their interest in the matter is secondary.
Mr Brown, the step-father of the deceased, continually raised concerns regarding the adequacy of the police investigation into Joanne’s death and raised this complaint with the Coroner ahead of the Inquest. Despite this the inquest went ahead and a verdict was given, based upon an investigation which has since been found to have been flawed. Many of Mr Brown’s complaints focus upon the relationship between the Coroner and the Police.
Whilst there is no finding of collusion and conspiracy between the Coroner and the Police, in his conclusions, Lord Justice Pitchford acknowledges that Mr and Mrs Brown had “legitimate concerns about the haste with which the investigation appeared to reach a preliminary conclusion and the lack of adequate consultation”. It seems clear that throughout the coronial process Mr Brown felt that he had much less of a voice than the Police who were assisting the Coroner with his investigations.
His Honour Judge Peter Thornton QC (Chief Coroner for England and Wales) identifies potential pitfalls for Coroners when dealing with the bereaved families and the need for “good practice” at the pre-inquest stage of the coronial process.
Coroners should at all times take care in their dealings with interested persons not to give the impression of bias or favouritism. Coroners may need to communicate with police officers investigating on their behalf but should do so in a way that will not engender concern to bereaved families that their interests were being treated as separately.
In addition, all interested persons, particularly bereaved families, should have sufficient notice of the matters to be discussed at Pre-Inquest Review hearings to ensure that families can prepare. In the case of Brown, the Claimant was given no notice of what was to be discussed at the Pre-Inquest Review hearing and was unprepared when asked which witnesses should attend to give evidence and whether he accepted that the cause of death could not be established.
It seems that there is finally a recognition of the frustration of bereaved families who find themselves suddenly and unexpectedly attempting to negotiate the complicated coronial system. Families must not be treated so as to feel like a spectator to the process and Coroners must remember in their dealings with the investigating parties (be it the Police or The Ministry of Defence) that the families should be at the heart of the coronial process.
by Gareth Jones, Hilary Meredith Solicitors