Challenging Coroner Decisions

When and How to Challenge Coroner Decisions

If you believe a coroner has made an incorrect decision, reached the wrong conclusion, or conducted an inquest unfairly, you have legal options to challenge. However, challenges are difficult, expensive, and rarely successful. Understanding the grounds for challenge and the processes involved is essential before proceeding.

Important: This is a complex area of law. You'll almost certainly need specialist legal advice before pursuing any formal challenge. This guide provides an overview but shouldn't substitute for professional legal counsel.

October 2025 Update:

Recent case law has clarified the grounds for challenging coroner conclusions, making it slightly easier to seek new inquests when significant new evidence emerges. However, challenges remain difficult.

Types of Challenges Available

1. Application for New Inquest

When: After an inquest has concluded with a conclusion you believe is wrong or insufficient.

Process: Apply to the Attorney General or Solicitor General (for England and Wales) to request the High Court order a new inquest.

Deadline: No strict deadline, but must be made within a reasonable time (usually within months, not years).

2. Judicial Review

When: To challenge the coroner's decision-making process or procedural decisions before or during an inquest.

Process: Apply to the High Court for judicial review of the coroner's decision.

Deadline: Must apply promptly, and in any event within 3 months of the decision being challenged.

3. Complaint to Chief Coroner

When: For concerns about how the investigation was conducted, delays, or coroner behavior.

Process: Write to the Chief Coroner outlining your concerns.

Outcome: Can result in guidance to the coroner, but won't overturn conclusions or order new inquest.

4. Complaint to Judicial Conduct Investigations Office (JCIO)

When: For serious complaints about the coroner's personal conduct.

Process: Submit formal complaint to JCIO.

Outcome: Can result in disciplinary action against the coroner, but doesn't change the inquest outcome.

Applying for a New Inquest

The most common way to challenge an inquest conclusion:

Grounds for New Inquest

You must show one or more of the following:

Insufficient inquiry: The coroner failed to investigate relevant matters
New evidence: Significant evidence has emerged that wasn't available at the original inquest
Irregularity: There was a serious procedural error in how the inquest was conducted
Legally deficient conclusion: The conclusion reached was not supported by the evidence or was legally wrong
Public interest: There's a compelling public interest reason for a new inquest

The Application Process

Obtain legal representation: This is essential. The process is complex and technical.
Gather evidence: Document why the original inquest was insufficient or incorrect.
Draft application: Your solicitor prepares detailed grounds for the application.
Submit to Attorney General: Application goes first to the Attorney General or Solicitor General.
AG consideration: They review and decide whether to apply to the High Court on your behalf.
High Court hearing: If the AG agrees, the High Court hears the application.
Decision: High Court decides whether to quash the original inquest and order a new one.

Realistic Success Rates

Applications for new inquests are rarely successful. The Attorney General receives around 50-100 applications annually and agrees to only about 5-10. The High Court then grants even fewer. You need very strong grounds.

Timeline

The process typically takes 6-18 months from application to decision, and if a new inquest is ordered, that adds another 12-24 months.

Costs

Expensive. Typical costs:

Legal fees for application: £10,000-£30,000
If successful and new inquest held: Additional £15,000-£50,000+
Legal aid is very rarely available
No costs recovery even if successful (you pay your own costs)

Judicial Review of Coroner Decisions

Judicial review challenges the decision-making process, not the conclusion itself:

What Can Be Challenged

Decision about scope of inquest (what should be investigated)
Refusal to call particular witnesses
Refusal to allow particular lines of questioning
Decision not to hold an inquest when one was required
Procedural unfairness during the inquest
Failure to provide adequate disclosure of documents

Grounds for Judicial Review

You must show the coroner's decision was:

Illegal: The coroner acted beyond their legal powers
Irrational: No reasonable coroner could have made that decision
Procedurally unfair: The process violated principles of natural justice

The JR Process

Pre-action protocol: Write to the coroner explaining your challenge and seeking resolution.
Permission stage: Apply to High Court for permission to bring judicial review.
Permission decision: Judge decides if you have an arguable case.
Full hearing: If permission granted, full hearing of the challenge.
Judgment: Court decides whether to quash the decision and what should happen next.

Timing is Critical

Judicial review must be brought "promptly" and in any event within 3 months of the decision. Delay can be fatal to your case even if you have good grounds.

Costs Risk

Judicial review carries significant costs risks:

Your own legal costs: £15,000-£50,000+
If you lose, you may have to pay the coroner's costs
Total exposure can exceed £100,000 in complex cases
Legal aid very rarely available

Complaints Process

For less serious concerns, the complaints process may be more appropriate:

Complaint to the Chief Coroner

When to use:

Concerns about how investigation was conducted
Unreasonable delays
Poor communication
Lack of family involvement
Procedural concerns

Process:

Write detailed complaint letter to Chief Coroner
Chief Coroner reviews and may contact the coroner
Response typically within 3-6 weeks

Outcome: Chief Coroner can provide guidance to coroners but cannot overturn decisions or order new inquests.

Complaint to JCIO

When to use:

Serious misconduct by the coroner
Inappropriate behavior
Bias or prejudice
Breach of judicial conduct standards

Process:

Complete JCIO complaint form
Provide detailed evidence of misconduct
JCIO investigates
Decision on whether disciplinary action warranted

Outcome: Can result in advice, warning, or in serious cases, removal from office. Doesn't change inquest outcome.

Local Resolution First

Before formal complaints, consider raising concerns directly with the coroner or senior coroner. Many issues can be resolved through direct communication.

Should You Challenge?

Important factors to consider before pursuing a challenge:

Reasons to Consider Challenging

Significant new evidence has emerged
Clear legal error in the conclusion or process
Important matters weren't investigated
Procedural unfairness prevented proper examination
Public interest in getting it right
You can afford the costs and emotional toll

Reasons to Think Carefully

Success rates are very low
Costs are substantial (tens of thousands of pounds)
Process takes many months or years
Emotionally exhausting and prevents closure
Even if successful, new inquest may reach same conclusion
You simply disagree with the conclusion (not enough on its own)

Get Expert Advice

Consult with a specialist inquest solicitor who can objectively assess your prospects. Organizations like INQUEST can help you find appropriate legal advice and may be able to assess whether you have grounds for challenge.

Alternative Routes to Justice

Sometimes alternative approaches achieve better results than challenging the inquest:

Civil Litigation

If your goal is compensation for negligence or wrongdoing, civil litigation may be more effective than challenging the inquest. Civil courts aren't bound by inquest conclusions.

Criminal Prosecution

If you believe a crime was committed, report to police or CPS. They make independent decisions about prosecution regardless of inquest conclusions.

Professional Regulation

Complain to professional bodies (GMC, NMC, etc.) about professional conduct. They investigate independently of inquests.

Health and Safety Prosecution

Report workplace safety concerns to HSE. They can prosecute employers regardless of inquest conclusions.

Public Campaigns

If your goal is systemic change, public campaigning may be more effective than legal challenges. Prevention of Future Deaths reports already highlight systemic issues.

Case Studies: When Challenges Succeed

Example 1: New Medical Evidence

Situation: Inquest concluded natural causes. Expert review commissioned by family found clear evidence of medical negligence not considered at inquest.

Outcome: Attorney General agreed to apply for new inquest. High Court ordered fresh inquest with broader scope.

Why it succeeded: Significant new expert evidence that was credible and directly contradicted original findings.

Example 2: Scope Challenge

Situation: Coroner narrowly scoped inquiry, excluding examination of systemic failures in mental health trust.

Outcome: Judicial review granted. Court found coroner should have examined wider systemic issues given Article 2 obligations.

Why it succeeded: Clear legal error in scope determination with significant human rights implications.

Example 3: Procedural Unfairness

Situation: Coroner refused to allow family to question key witnesses, significantly limiting their participation.

Outcome: Judicial review succeeded. Court found breach of Article 2 procedural obligations.

Why it succeeded: Fundamental procedural unfairness preventing effective investigation.

Practical Steps to Challenge

If you've decided to pursue a challenge:

Document everything: Keep detailed notes of all concerns, preserve all correspondence, gather supporting evidence.
Obtain inquest transcript: Order the official transcript of the inquest hearing (expect to pay several hundred pounds).
Get specialist legal advice: Consult a solicitor experienced in inquests and judicial review.
Consider funding: Understand costs, explore legal aid eligibility (unlikely), consider crowdfunding or legal expenses insurance.
Obtain expert evidence: If challenging conclusions, you'll likely need expert opinion supporting your position.
Move quickly: Judicial review deadlines are strict. Don't delay.
Prepare emotionally: The process is draining and takes years. Ensure you have support.

When Challenges Fail

Most challenges are unsuccessful. If your challenge fails:

Accept the outcome: Courts very rarely allow appeals of challenges. Further legal action is usually futile.

Pursue alternatives: Consider civil litigation, professional complaints, or campaigning instead.

Seek closure: At some point, continuing to fight prevents healing. Bereavement counseling can help.

Channel energy positively: Some families find meaning in campaigning for systemic change rather than focusing on their specific case.

Reality Check

Before embarking on a challenge, understand these realities:

• Success rate: Less than 10% of applications result in new inquests or successful judicial reviews
• Cost: £20,000-£100,000+ in legal fees with no guarantee of success
• Time: 1-3 years for the challenge process, plus another 1-2 years if new inquest ordered
• Emotional toll: Prevents closure and keeps you reliving the death
• Limited outcomes: Even if successful, new inquest may reach the same conclusion
• No compensation: Challenges don't award money – civil claims are separate

Getting Help and Advice

• INQUEST: 020 7553 0174 / inquest.org.uk – Free advice on whether challenge is viable
• Specialist Solicitors: Find via Law Society or INQUEST referrals
• Public Law Project: May assist with public interest cases
• Legal Aid Agency: Check eligibility (very limited for inquest challenges)
• Citizens Advice: General guidance on process and rights

Questions to Ask Your Solicitor

• What are my realistic prospects of success?
• What will this cost in total (including worst-case scenario)?
• How long will it take?
• What's the best possible outcome if we succeed?
• Are there alternative routes that might achieve my goals?
• What happens if we lose?
• Do you have experience with successful challenges?

Scotland and Northern Ireland

Scotland

Challenges to Fatal Accident Inquiry determinations are made through the Scottish courts. The process is similar but governed by Scots law. Consult a Scottish solicitor experienced in FAIs.

Northern Ireland

Northern Ireland has similar challenge mechanisms to England and Wales, with Attorney General for Northern Ireland handling applications for fresh inquests.