Brown v HM Coroner for the County of Norfolk & Anor

This is an application made by the claimant with the authority of the Attorney General for an order under section 13(1)(b) of the Coroners Act 1988 (as amended) that the inquest held on 15 September 2011 into the death of Joanne Foreman be quashed and that a fresh coroner’s investigation should be held.

The claimant, Ernest Andrew Brown, is the step-father of the deceased, Joanne Foreman, who was born on 21 April 1969 and died on 12 March 2011. Henceforward I shall refer to her as Joanne or ‘the deceased’. Mr Brown has appeared in person to present his application. Counsel, Ms Eloise Power, has appeared for the then Coroner of Norfolk, since retired, and Ms Alison Hewitt for the interested party, the Chief Constable of the Norfolk Constabulary.

It is ground common to all sides that the police investigation which took place into the circumstances of the death of Joanne Foreman was inadequate. In consequence, in at least one important respect the evidence presented to the Coroner at the inquest was incomplete and inaccurate. The issue that arises in this application is whether it is in the interests of justice that another investigation should be held. The verdict reached by the Coroner was a narrative one as follows:

“It is not possible to reach a safe and reliable conclusion as to how Joanne Foreman died. She did not take any action [with the intention] of ending her life and no other person caused her death.”

In the course of his findings which culminated in the verdict, the Coroner excluded the possibility that the deceased had been unlawfully killed or that she had taken her own life. However, he recorded that there existed a real possibility that Joanne, who was not a diabetic, had self-injected insulin and consumed alcohol in combination which may have caused her death. The Coroner was unable on the evidence to find that this was the cause of death. Subsequent enquiries have effectively eliminated the possibility that the taking of insulin even if it occurred could have made any significant contribution to death.

It is clear from the Coroner’s notes of his pre-inquest review that the parties proceeded upon the mistaken assumption that although the precise cause of death could not be ascertained the self-ingestion of insulin and alcohol may well have been the cause. As a result a substantial number of enquiries which could have been made were not. The error was appreciated only after the inquest, when the claimant made his formal complaint, and since then a substantial body of further evidence has been obtained. While it is not possible to conclude that the verdict following a fresh inquest is likely to be different, I have reached the conclusion that upon this common ground alone it is in the interests of justice that a new inquest should be held. It is on the facts of this case a denial of justice that there remain public findings by the Coroner which are known to be inaccurate in a material respect.

Nonetheless, the claimant has insisted upon advancing, as further grounds for his application, his assertion that the Norfolk Constabulary and others have relentlessly pursued an attempt to cover up the deficiencies in the original investigation, to “rig” the Coroner’s inquest and to deny the deceased’s family access to information relevant to Joanne’s death. These allegations are so serious that, in my view, this court would be failing in its duty if it did not confront them. In order to set them in their context I shall first describe in uncontentious terms the results of the early stages of the investigation.

At the time of her death Joanne lived at 28 St Helena Way, Horsford, Norwich with Adrian Gayton and Mr Gayton’s 15 year old son. The son who was a diabetic had been prescribed doses of insulin delivered by means of an injection pen. They were stored in the family home. On 10 March 2011 Joanne did not attend her work as a shop floor manager at H & M saying that she felt unwell. On 11 March she left work early suffering from what she described as a bug. On the following day, Saturday 12 March, she was due to take responsibility for a shift at the store. Her manager wished to ensure that she would be fit to carry out that duty and advised her to leave work early on the Friday. That afternoon she went with Adrian Gayton to their local public house, the Brickmakers which was a short walk from their home. During the course of the afternoon and evening she was seen to use a half bottle of gin to charge the glasses of tonic water she purchased at the pub. Adrian and Joanne left the public house together at about 7 – 7.30 pm and returned home. Shortly afterwards Mr Gayton left 28 St Helena Way leaving Joanne alone. Mr Gayton’s son was staying with a friend, Annie Watson, who lived a short distance away. He joined them. At some stage that night Mr Gayton returned to 28 St Helena Way. At 8.19 am on 12 March Mr Gayton telephoned the emergency services. Between approximately 8.25 am and 8.30 am emergency care practitioners arrived at the house. The first to arrive was a paramedic, Nicholas Pritchett, who was taken by Mr Gayton to the first floor front bedroom where he saw Joanne lying on her back on the bed. Shortly afterwards, Andrew Downes, Ben Caine and Dr Pamela Chrispin attended. Joanne’s body was lifted to the floor where emergency resuscitation was attempted. At 8.43 am Dr Chrispin declared that Joanne was dead. Dr Chrispin spoke to Adrian Gayton in the living room. She explained that this was a sudden death and the police would be informed. She advised that he should call someone to be with him. Using Dr Chrispin’s telephone he contacted Jayne Wright, a mutual friend of Joanne Foreman and Adrian Gayton, who had been drinking with them in the Brickmakers and was still there when they left. She arrived at 28 St Helena Way shortly after the call and remained for a time with Mr Gayton. PC Matthew Pritty arrived at approximately 9.05 am.

Jayne Wright and Adrian Gayton were in the living room. PC Pritty spoke to one of the paramedics or to Dr Chrispin who stated that there appeared to be no marks on the deceased’s body. He made his way to the bedroom where he also made a physical check. He could see no marks. On returning to the ground floor PC Pritty spoke to Adrian Gayton and Jayne Wright. Gayton appeared to be extremely distressed. He informed PC Pritty that he and Joanne had gone to the pub the previous day. On their return home an argument had broken out as a result of which he left the house. He returned at 3.00 am and could hear Joanne snoring upstairs. He slept on the sofa with the dog. At about 8.00 am he went up to the bedroom and found Joanne apparently dead.

At 9.50 am PC Pritty contacted undertakers. At 11.00 am Joanne’s body was removed by the undertakers. At 12.50 pm PC Pritty attended Joanne’s parents’ address where he spoke to the claimant and Mrs Suzanne Brown, her mother. On his return to Taverham Police Station at 1.45 pm PC Pritty telephoned Jayne Wright. Jayne Wright informed him that during the previous evening Joanne may have used an insulin injector pen to inject herself after the argument with Adrian Gayton. Jayne Wright said that the pen was recovered and taken into the Brickmakers public house. At 2.10 pm he collected the insulin pen from Jayne Wright. At 4.30 pm he deposited the insulin pen with Duckers undertakers at Aylsham with the intention that it should accompany the body for the post-mortem.

On 15 March 2011 Professor Richard Ball, a consultant histopathologist, carried out a post-mortem examination upon Joanne’s body. He found no external sign of injury and no apparent cause of death. Toxicological analysis revealed only a low concentration of quinine, a constituent of tonic water. No alcohol or other drug was detected in the post-mortem blood sample. The sample was not suitable for analysis of any ingestion of insulin. No other relevant findings were made. Professor Ball found that the cause of Joanne’s death was “unascertained”.

On 17 March 2011 Lorraine Marshall, the Norfolk Coroner’s officer requested enquiries to be carried out on behalf of the Coroner. At 6.00 pm on 17 March 2011 Detective Sergeant (“DS”) Clabon and Detective Constable (“DC”) Thompson took a statement from Adrian Gayton. In that statement Mr Gayton said that upon their arrival home the evening before Joanne’s death she had “flipped out”, struck and kicked him. As a result he suffered scratches. He walked out of the door. At about 2.45 am he returned to the house and could hear Joanne upstairs snoring. He went to sleep on the sofa with the dog which woke him up about 6.30 am. He let the dog out and could still hear Joanne snoring in her sleep. Just after 8.00 am he went upstairs knowing that Joanne needed to report for work. At this time there appeared to be no sign of life. He telephoned the emergency services.

A statement was also taken from Jayne Wright who said she had spent part of the afternoon and evening of 11 March in the Brickmakers with Adrian and Joanne. They left in the evening. She confirmed that although Joanne had, since January, been drinking no alcohol she had, that day, been charging her glass from a half bottle of gin. She said that Joanne returned to the Brickmakers at about 8.00 pm and handed her the dog on a lead. She was upset and angry because she had rowed with Adrian but she did not go into detail. She also handed Jayne her door key for some reason she did not explain. Joanne was asked to leave the public house but she returned on a second occasion. Jayne stood with her outside. Joanne told her that she had “done the insulin”. Jayne went into the pub to get help. Two male customers came outside. One of them found what looked like a felt tip pen, picked it up and left it behind the bar. Joanne had gone.

Later, a witness statement was obtained from Annie Watson, the neighbour with whom Mr Gayton’s son had stayed overnight. She said that when Adrian Gayton arrived at 4 Bracken Close on the night of 11 March there was blood on his face, he was limping and he had bite marks on his thigh and abdomen.

The results of the further enquiries made by DS Clabon and DC Thompson were reported to the Coroner’s office. The officers believed that the cause of death was unknown but it was probable that death was the result of natural causes or an insulin overdose.

On 23 March 2011 someone who was aware of the enquiry suggested to another officer, DC Wright, that insulin could be injected between the toes without leaving a trace. On 24 March the same person made a further call to the Coroner’s office. That person was seen by DC Thompson and DS Clabon just after 3.00 pm on 24 March. It was apparent that the witness could make no meaningful contribution to the enquiry. Joanne’s funeral took place that day and her body was cremated.

On 25 April 2011 Mr Brown commenced an email correspondence with DS Clabon. He expressed anxiety about the accounts given by Adrian Gayton. Mr Brown was concerned that Mr Gayton’s attitude towards Joanne’s estate had changed since her death. Those concerns were repeated at a face to face meeting with Mr and Mrs Brown on 9 May 2011.

On 25 May 2011 DS Clabon sought from Professor Vincent Marks, an expert in diabetes and insulin, an opinion as to the possible cause of Joanne’s death. Professor Marks was informed that Joanne may have ingested insulin on top of a quantity of alcohol during the afternoon and evening of 11 March. On 31 May Mr Brown sent an email to DS Clabon expressing his continuing concerns at the possible involvement of Adrian Gayton in Joanne’s death. He sought an independent reassessment of the investigation. On 1 June 2011 Detective Chief Inspector (“DCI”) Firm accompanied DS Clabon to Mr and Mrs Brown’s home in order to provide an update. On 5 June 2011 DS Clabon visited Adrian Gayton to seek further information relating to Mr Brown’s concerns. According to DS Clabon he met Mr and Mrs Brown on 11 June 2011 when both of them expressed their contentment with the conclusions expressed in his report to the Coroner. However, on 25 July Mr Brown sent an email to DS Clabon in which he repeated his unhappiness with the contents of the statements made by Adrian Gayton and Jayne Wright.

In the meantime, on 14 June 2011 Professor Marks sent a preliminary report to DS Clabon in which he said:

“The autopsy and toxicology screen provided no clues to the cause of Ms Foreman’s death as might be expected if it was due, as I strongly suspect it was, to the lethal combination of alcohol and insulin induced hypoglycaemia. Insulin is ordinarily a very safe drug and extremely few people who use it properly for therapy of diabetes die from it. … Even when taken in potentially suicidal doses death from insulin induced hypoglycaemia is rare unless the insulin is also taken with alcohol. This combination, for some reason still not properly understood, makes hypoglycaemia unusually lethal. The dose of neither insulin nor alcohol need itself be sufficient to cause death or even severe damage. The alcohol might have all been destroyed by metabolism in the liver before death occurs as I believe happened to Ms Foreman.”

On 12 August 2011 Mr Brown raised with DS Clabon his anxiety as to the evidence that Joanne handed a door key to Jayne Wright. If that were so he wondered how Joanne got back into her house. DS Clabon made an enquiry of Adrian Gayton as to the number of keys in existence. Mr Brown’s response on 17 August 2011 was to criticise DS Clabon for alerting Adrian Gayton to the emergence of inconsistencies in the evidence. Mr Brown was particularly concerned that DS Clabon had carried out no investigation of the mobile telephone traffic between Adrian Gayton, Jayne Wright and others during the night of 11/12 March. At a meeting between DCI Firm, DS Clabon and Mr and Mrs Brown on 2 September 2011, Mr Brown left the room in temper. He considered that the investigation had been incompetent and that he and wife were not being treated with appropriate respect (see also paragraph 25 below).

On 4 September 2011 Mr Brown sent a long email to the Coroner in which he complained bitterly about the conduct of the investigation and the behaviour of police officers towards him and his wife. He was particularly concerned about the decision to release Joanne’s body for cremation which he said was done despite his “protestations”. He felt strongly that there was reluctance among the officers involved to get to the bottom of Joanne’s death. Mr Brown sought an opportunity to meet with the Coroner before the inquest so as fully to express his concerns as to the inadequacy of the police investigation. On 7 September 2011 Mr and Mrs Brown attended the Coroner’s office for a pre-inquest review. They were waiting in a room alongside the Coroner’s office when it became apparent to them that the Coroner was speaking to DCI Firm and DS Clabon in their absence. Mr Brown asserts that he could overhear DCI Firm describing the deceased as aggressive, suicidal and drunk, and describing Mr Brown as difficult. So incensed was Mr Brown that he entered the Coroner’s room and informed the occupants that he and his wife could hear what was being said. DS Clabon accepts that during their meeting with the Coroner DCI Firm explained that the deceased had had a drink problem and that Mr Brown had been a difficult man to deal with because he would not accept what he was being told by the police. The officers were concerned that he would use the opportunity at the inquest to question Adrian Gayton and Jayne Wright with a view to establishing that they were in some way to blame for his daughter’s death. DCI Firm accepts that he summarised the evidence relating to Joanne Foreman and that he may have used words such as “needy”, “insecure” and “aggressive at times” to describe her.

It seems to me entirely understandable that Mr and Mrs Brown should, as a result of this experience, have felt marginalised by the process that was taking place. They were attending what they understood to be a meeting of interested persons preparatory to the inquest yet the officers with whose efforts they were, rightly or wrongly, dissatisfied were being given access alone to the Coroner, the Coroner knowing from Mr Brown’s email of 4 September 2011 of their unhappiness. No doubt, as the officers were carrying out enquiries on behalf of the Coroner, this was merely a preliminary discussion of issues. However, the effect was to engender in Mr and Mrs Brown a concern that their interest was being treated as secondary.

At the pre-inquest review which followed on 7 September, attended by Mr and Mrs Brown, Adrian Gayton, Jayne Wright, DCI Firm and DS Clabon, Mr Brown complained that he had not received copies of the post-mortem and toxicology reports. He was told that he would be provided with them before the final hearing. No-one sought the attendance of Professor Marks at the hearing fixed for 15 September. No-one appreciated that there was evidence in existence which would undermine Professor Marks’ opinion. The only witnesses who would be required to attend were those present at the review. In his submissions to the court Mr Brown emphasised that he had wanted PC Pritty to attend the inquest but was told that he was not available on 15 September; if PC Pritty was to attend, the inquest would have to be adjourned. No note of that concern was made at the time of the review. In the light of the conclusion I have reached upon the need for a new inquest it is not necessary to resolve whether the note taken was incomplete. Mr and Mrs Brown did not wish any adjournment of the inquest. Accordingly, PC Pritty’s evidence was to be summarised. Mr Brown complained that he had not been given all the information he considered necessary but the Coroner “made it absolutely clear that he would have the right to ask questions of the police and of Adrian Gayton and Jayne Wright”. However, the purpose of the inquest was, he said, to establish how Joanne died and “not to carry out a detailed investigation into the history and nature of the relationship between her and Adrian Gayton”. The Coroner would decide what should be the ambit of the inquest. Mr and Mrs Brown accepted that the cause of death could not be established and did not challenge Professor Marks view that the ingestion of insulin was the likely cause. The Coroner indicated that in his view this was not a case for a jury but he would consider any submission made by Mr Brown to that effect. Mr Brown did not pursue the suggestion. Mrs Brown was concerned that Joanne’s character may be misrepresented at the inquest and wanted to ensure that she was able to redress the balance. The Coroner emphasised that Mrs Brown would be given the opportunity to give evidence about her daughter and “it was not part of the function of the inquest to criticise Joanne”.

At the inquest on 15 September Adrian Gayton revealed for the first time that not only had he been scratched and kicked on his return home with Joanne on the evening of 11 March but he had also suffered significant bites. It is clear from the transcript of the proceedings that Mr Brown wished to explore Adrian Gayton’s evidence in some detail. He asserted in argument to this court that he was prevented by the Coroner from doing so. A further cause for Mr and Mrs Brown’s exasperation with the process is that the transcript is incomplete. We were informed that a new recording system with teething problems had been installed. The result was that sections of the proceedings, including Mr Brown’s cross-examination of Adrian Gayton, are missing from the transcript. At one stage it was being suggested by Mr Brown that the recording had been tampered with. I reject that suggestion. A perfectly sensible explanation has been provided by an expert.

Of fundamental significance is the fact that the inquest was conducted upon a general understanding that Joanne had self-injected insulin which may have been the cause of her death. Neither the police nor the Coroner’s officer, drew to the attention of Professor Marks or the Coroner the findings of the paramedic team which included a blood glucose analysis made at the scene. That reading was entirely normal in which case, it was the preponderance of the expert evidence subsequently obtained, insulin can have played no significant role in Joanne’s death.

Mr Brown was dissatisfied with a number of aspects of the investigation and the inquest. On 26 September 2011 he made a formal complaint to the Professional Standards Department of Norfolk Constabulary. In consequence parallel investigations were carried out, first into the complaints made by Mr Brown against the police. The investigating officer was DCI Shane O’Neill. In opening his report of 11 July 2012 DCI O’Neill said this:

“You first contacted the Norfolk and Suffolk Professional Standards Department (PSD) on 4 August 2011 via telephone to express your concerns regarding the investigation into the death of your daughter, Joanne Foreman, who died earlier in the year on 12 March 2011. Following a meeting on 9 August with DS Shaw and Mr Allen from PSD, and a sequence of telephone calls and emails, you formally complained via email on the 26 September 2011 about DS Clabon, DS Shaw, DCI Firm and Detective Superintendent Dean. This was recorded by PSD under reference PS/401/11/SC. You met with Mr Fernandes on 6 October, then DCC Bailey on the 14 October during which he decided that any complaints you had would be investigated by the joint Hertfordshire and Bedfordshire PSD. In addition DCC Bailey agreed that DCI Neil Luckett from the arm of the Major Investigation Team (MIT) based in Suffolk would be asked to conduct a review of the investigation into Joanne’s death, and would reinvestigate the circumstances surrounding her death.”

Mr Brown made a total of 19 specific complaints of which four were upheld. The first was that DCI Firm had attended a meeting with Mr and Mrs Brown on 9 June 2011 unprepared to present the findings of his review of the investigation. Secondly, DCI Firm intimidated Mrs Suzanne Brown at a meeting on 2 September 2011. Thirdly, Detective Superintendent Dean failed to ensure that a thorough review of the investigation into Joanne Foreman’s death was conducted by DCI Firm. Fourthly, DS Clabon, having been informed by Annie Watson that she had seen Mr Gayton with “severe bite marks” on his body failed to investigate their significance.

A parallel reinvestigation was conducted by DCI Neil Luckett. During the course of the reinvestigation a substantial number of further statements were taken. Mr and Mrs Brown have not had access to the source material, only to DCI Luckett’s summary report of 2 July 2012. In his conclusion DCI Luckett said:

“66.

The inquest verdict was based on an investigation which was flawed in some aspects. This may not have affected the verdict as the pathological cause of death remains “unascertained” but some information supporting that verdict was incorrect. It is a matter for the coroner or other interested parties to consider whether this may or may not have affected the verdict.

67.

Despite a thorough reinvestigation, the key question remains about exactly what happened to Joanne Foreman from the time she was last seen leaving the Brickmakers public house to the time she was discovered on the morning of 12 March 2011.

68.

This investigation has considered a number of hypotheses about how Joanne Foreman died. These are now primarily that death occurred through natural causes or that she could have been unlawfully killed. There is no significant evidence currently available to this enquiry which will assist in clearly determining whether either hypothesis is true. Hence the cause of Joanne Foreman’s death unfortunately remains as unexplained.”

DCI Luckett’s identification of the outstanding question is accurately stated at paragraph 67 of his report. His further enquiries revealed an abundance of evidence that when Joanne left the Brickmaker’s public house for the last time on the evening of 11 March she appeared to be upset but not injured.

Mr Brown was dissatisfied about the conclusions upon his complaints and the further investigation. He appealed against DCI O’Neill’s conclusions to the Independent Police Complaints Commission. On 31 October 2012 his appeal was dismissed. In the meantime Mr Brown sought to make further complaints about the police investigation. Norfolk Police Authority “dispensed” with his complaint. Again, Mr Brown complained to the IPCC and on 11 December 2012 the Commission declined to accept the complaint. Further complaints were dismissed on 14 May 2012.

In the meantime, however, a review of DCI Luckett’s reinvestigation was performed by Mr Kevin Macey of the Kent and Essex Serious Crime Directorate Review Team. In his submissions to the court Mr Brown recognised that Mr Macey’s review was of a high quality. In his conclusions were included the following observations:

“226.

The review recognises and this report mentions at several points the limitations operating on the inquiry arising from both the decision not to treat the death as suspicious and subsequently the decision to recommend release of Joanne’s body in the face of reported concerns without further investigation. Indeed Dr Swift, the Home Office pathologist makes much the same point in his expert advice to the inquiry. The reader will of course be mindful of his fundamental point since it dominates all other considerations. …

227.

This review does not underestimate the extent of the investigative knowledge accumulated through interviews of witnesses and analysis of passive data. The whole picture is still incomplete but a significant amount is known to the investigation. Only a small part of that knowledge has been shared with Joanne’s parents and this aspect is the first to be the subject of recommendation from this review.

228.

From the very first publication of the murder investigation manual, the Macpherson Report and other doctrinal guidance emanating from ACPO’s Homicide Working Group, occupying the very core of investigative thinking has been the belief that families are integral partners in the investigation of death. Whilst there are obvious difficulties with regards to individual’s rights and some legislative restrictions, this review suggests there is no compelling justification for withholding the full account of the investigation from Joanne’s family, if they wish to be told. The limited information provided to Mr and Mrs Brown for example is matched only by the quest for knowledge that has followed the earlier contact and a sense of frustration that is palpable and with which few would not find sympathy. This review also notes the Browns have “dispensed with the services of the Family Liaison Officer”. Accordingly this review proposes the Commissioning Officer considers how fuller revelation of the investigative knowledge can be provided to those in Joanne’s family who wish it, including provision of a copy of this review report. In this sense Joanne’s family clearly extends beyond Mr and Mrs Brown.

Mr Macey identified a limited number of areas in which further enquiries might be made so as to complete the knowledge available to the investigation. Further enquiries were made and Mr Luckett, now Detective Superintendent, submitted a response dated 29 October 2013. Mr Brown remains dissatisfied.

I have summarised some of the important events, particularly those which took place before and at the time of the inquest, and have expressed an understanding why it should be that Mr Brown regards the investigation into his daughter’s death as completely unsatisfactory. One can only express sorrow that at such a painful time for Joanne’s family they are beset with worry that they have been let down. Unhappily, however, Mr Brown, who is clearly an intelligent and experienced man, has lost his sense of proportion. He has repeatedly asserted in writing and in argument that officers of the Norfolk Constabulary and the Professional Standards Department which investigated his complaints have conspired together to conceal or obscure the failings in the original investigation. More particularly, he alleged that DCI Firm and DS Clabon conspired with the Coroner to ensure a predetermined open verdict. In order to assist the court’s understanding of Mr Brown’s submissions we received from him his notes for argument in four separate documents entitled “Sequence of Events”, “Luckett”, “Telephones” and “Wright”. Mr Brown recognised in the course of his oral submissions that he had made assertions in those documents which, on reflection, he would prefer to modify. Nonetheless Mr Brown revealed no hesitation in making extremely serious allegations of dishonesty and misconduct both by police officers and by the Coroner. Mr Brown seemed unwilling to recognise as genuine the acknowledgement by DCI Luckett of the failings in the original investigation or that his reinvestigation was a genuine attempt to put the matter right.

In the course of his submissions the claimant made a number of assertions, some of them contradictory. At one moment he said that Joanne was ‘possibly’ or ‘probably’ murdered; at another he said he was not saying that anybody killed Joanne. He asserted that Adrian Gayton had been ‘acting’. He claimed that the scene of Joanne’s death had been tidied up and ‘bleached’. Evidence, he said, had been tampered with or destroyed. The Coroner had made up his mind before the inquest what the verdict would be and he and the police were engaged in a conspiracy to “rig” the inquest. He claimed, without evidential justification, that the ‘key’ to Joanne’s death was ‘Wright’, meaning Jayne Wright, and that the police “have used Gayton and Wright to fabricate evidence to present to the Coroner”. Finally, the claimant felt able to allege that the signatures on a copy of Professor Marks’ preliminary report supplied to Mr and Mrs Brown under cover of a letter dated 16 June 2011 had been forged. Despite the observations of the court in the course of argument Mr Brown continues to make the allegation without a shred of evidence to support it.

I unhesitatingly reject Mr Brown’s assertions of misconduct and dishonesty by the police, Professor Marks or the Coroner. None of them is justified by the evidence that this court has seen, which includes the full reports prepared by DCI O’Neill, DCI Luckett and Mr Macey. As Mr Macey observed in his report the investigation had been hampered by the early judgement made by PC Pritty that Joanne’s was not a suspicious death. It seems to me 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. Those concerns have been acknowledged by DCI Luckett and Mr Macey respectively. There is no doubt that the information available to the Coroner was incomplete and inaccurate. In my judgment, it was this failing which led to an inquest that was less than satisfactory. Mr Brown excepted from his most stringent criticisms the work of PC Pritty whom he regards as an honest policeman. There is little doubt that, had PC Pritty fully understood the implications at the time of his visit to the deceased’s home, he would have sought the assistance of more senior officers and preserved the scene as a suspicious death. In consequence, a post-mortem would have been carried out by a Home Office forensic pathologist and a full and detailed written and photographic record made before the deceased’s body was released for cremation. The fact that this did not occur has resulted in unmerited speculation as to the possible causes of Joanne’s death.

I wish to make it clear that nothing I have said in this judgment should be taken to indicate any conclusions, even provisional, as to the outcome of a further inquest. As I understand the claimant’s submissions he wishes to explore some of the inconsistencies that have arisen in the evidence and the loose ends that remain. He recognises that the immediate cause of death may remain unknown. I see no reason, however, why Mr and Mrs Brown should be denied access to the evidence gathered by DCI Luckett’s reinvestigation, subject to the usual Public Interest Immunity considerations. It will be the responsibility of the Coroner at the fresh inquest to determine to what extent and for what purposes the questioning of witnesses may be permitted and Mr Brown must abide by the Coroner’s rulings. Having read the recommendations made by my Lord in a field in which he is expert, I can only concur.

I would grant the application, quash the inquest and inquisition and order that a fresh investigation should be held by the current Senior Coroner for Norfolk, or an appropriate coroner nominated by her.

I agree. As a result of the blood sugar level finding by the paramedics not being available to the coroner, the medical side of the investigation into the sad death of Joanne Foreman set off in the wrong direction and never got back on track. The absence of that finding was so significant that it is necessary and desirable in the interests of justice that a fresh investigation and inquest be held.

I would add this. I agree that the claimant, Mr Ernest Brown’s, assertions of collusion and conspiracy between the police and the coroner are without foundation. Some of his assertions, some more extreme than others, relate to the conduct of events at the pre-inquest review hearing held by the coroner on 7 September 2011. These assertions, I emphasise, have not been tested in evidence. The coroner has not been asked to respond to them for the purpose of these proceedings. They remain assertions, no more. Nevertheless they tend to identify potential pitfalls for coroners in their handling of pre-inquest review hearings, as I shall endeavour to show, which could be avoided by good practice.

The status of the pre-inquest review is now enshrined in rule 6 of the Coroners (Inquests) Rules 2013 (in force from 25 July 2013 for investigations started before and since). Rule 6 permits the coroner to hold a pre-inquest review hearing ‘at any time during the course of an investigation and before an inquest’. Rule 26 of the 2013 Rules requires a coroner to make and keep a recording of a pre-inquest review hearing. This requirement means that a coroner conducting such a hearing should take reasonable steps to ensure that the recording equipment is working well and that those who speak in court do so in such a way that the recording can be transcribed with accuracy and in full. An incomplete transcript is not helpful. It may open the door (as in this case) to allegations of tampering and deliberate and fraudulent removal of key questions and answers.

A pre-inquest review hearing, where held, is an important stage towards the final hearing. In each case the coroner should ensure that all interested persons, particularly bereaved families, have sufficient notice of the matters to be discussed at the pre-inquest review hearing. The claimant asserted in this case that he had no notice of what was going to be discussed at the hearing and was therefore unprepared when asked which witnesses should attend to give evidence and whether he accepted that the cause of death could not be established. Coroners should therefore provide a written agenda in advance and, if appropriate, express provisional views so that agreement or opposition can be expressed.

The agenda which should be tailored to the individual case should include, amongst other things, and particularly in the more complex or difficult cases, a list of interested persons, a proposed list of witnesses identifying those who may be called and those whose statements may be read, the issues to be considered at the inquest, the scope of the evidence, whether a jury will be required, whether Article 2 of the European Convention on Human Rights is engaged, any issues of disclosure, the date of the final hearing, and any other relevant matters. In a complex or difficult investigation interested persons should be invited to respond to the coroner’s agenda in advance of the pre-inquest review hearing in writing, stating what they agree with and what they do not agree with.

The coroner should also ensure that interested persons, particularly those unrepresented, have sufficient disclosure of relevant statements and documents before the pre-inquest review hearing so as to be able to address the agenda on an informed basis. The claimant asserted in this case, as the coroner’s note of the hearing states, that ‘he had not received copies of the post mortem and toxicology reports’. If correct, that would have placed him at a considerable disadvantage for the pre-inquest review hearing.

The claimant’s view of the pre-inquest review hearing was that the coroner had made up his mind what the outcome of the inquest would be. Coroners should avoid giving the impression at a pre-inquest review hearing (and in any documentation supplied before it) that the findings and conclusions of the inquest are in any way pre-determined, even when the evidence points substantially in one direction. It may be necessary to explain in clear language to unrepresented families that there is a difference between seeking to identify the key issues and coming to a final conclusion.

Another complaint by the claimant was that on the day of the pre-inquest review hearing and shortly before the hearing, he and his wife saw two key police witnesses in a private room with the coroner discussing the case (as confirmed by one of the two witnesses, DS Clabon, during the subsequent investigation of the claimant’s allegations against the police). 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 to police officers investigating on their behalf, but their communications, whether oral or written, should be made in such a way that they will not, as Lord Justice Pitchford expressed it, engender concern to others that their interests were being treated as secondary.

A coroner should therefore be careful in correspondence with an interested person, such as the police, not to appear to be too familiar or close to the correspondent and not encourage the same from the correspondent, even though the coroner may know the correspondent well in the course of coroner work. This was one of the claimant’s complaints. Even the use of first names may not look good to an outsider, particularly to somebody of the older generation. Coroners should only write letters (and emails) in the course of their work which will stand the test of looking fair and unbiased if and when read out in court in litigation.

These remarks are not intended to express a view one way or the other on the merit of some of the claimant’s individual complaints, but are made in the hope that repeated good practice will avoid or at least reduce the number of complaints which may be levelled at coroners in the future, particularly about pre-inquest review hearings.