Margaret Hunter v HM Assistant Coroner for County Durham and Darlington

Roisin Hunter Bennett died on 16^th March 2022. She had taken her own life, having suspended herself on 7^th March 2022, suffering a hypoxic ischaemic brain injury and dying in hospital some days later.

The claimants to this claim are Roisin’s parents. The defendant is the Assistant Coroner for County Durham and Darlington. He presided over the inquest into her death which concluded on 30^th January 2023.

There is no dispute about the defendant’s conclusion that Roisin’s death was as a result of suicide. The circumstances of her death were recorded at box 3 of the Record of Inquest form as follows:

“Roisin Hunter Bennett at Darlington Memorial Hospital on 16^th March 2022 after hanging herself by a cord from a wardrobe in her bedroom at 40 Pierremont Crescent, Darlington, on 7^th March 2022. That deliberate act by her caused a hypoxic ischaemic brain injury which caused her death and was her intention.

Her specific motivation to act as she did is not clear on the evidence available, but on balance derived from her low mood due to the ending of a relationship and the pressure of balancing work and studying for examinations”.

The claimants were immediately concerned about the wording of the second paragraph of box 3, specifically the finding about the cause of Roisin’s low mood. The claimants issued a letter before action under the pre-action protocol on 18^th April 2023, disputing the wording of that paragraph, and asserting that the defendant should have recorded instead words to the effect that “Her specific motivation to act as she did is not clear on the evidence available, but on balance derived from her low mood due to an emotionally-abusive relationship”.

It is clear that during the inquest the defendant heard and saw evidence of Roisin having been in such an abusive relationship that ended in the month before her death. There was evidence that she continued to receive abusive messages from her ex-partner, including on the day before she hanged herself. Her ex-partner, Mr. Henderson, is the interested party to these proceedings.

Moreover, the defendant made formal findings of fact, that are relevant to this issue, including that (i) the proximate circumstances of Roisin’s death included that her “long-term relationship had ended and a new one had begun only one to two days earlier”; (ii) this had led to “abusive messages to Roisin from her previous partner”; (iii) the evidence was “suggestive of a relationship marred by arguments and distress”; and (iv) Roisin had sought, in conjunction with her mother, support during this relationship where she disclosed “depressive thoughts arising from the relationship”.

The defendant also found that the abuse “seems to have culminated on the 6^th of March 2022, so much so that it led to her mother to chaperone her on that day, so concerned as she”.

Finally, the defendant found that one of the threads of causation was “the ending of a longstanding, turbulent relationship and the emotional turmoil associated with that [relationship]”.

It is therefore clear that the defendant had concluded that (i) Roisin’s earlier relationship was a turbulent and abusive one; (ii) the abusive messages continued at least until the day before she took her own life; (iii) the relationship impacted upon her mental state and contributed to her depressive thoughts; and (iv) as such the abusive relationship more than minimally contributed to the mental state that led to her death.

After receipt of the pre-action correspondence, the defendant agreed that in distilling a brief neutral summary from his findings of fact into box 3, he had overlooked recording on the formal Record of Inquest that a feature of the relationship was that it was emotionally abusive. The defendant accepted that he should have recorded this fact.

The parties now agree that it would be appropriate to delete the phrase “ending of a relationship and the pressure of balancing work and studying for examinations” from the second paragraph of box 3, and replace it with the phrase: “an emotionally abusive relationship”. This is because such revised wording is consistent with the findings that the defendant actually made, intended to make and that were justified by the evidence.

The defendant is functus officio and a Record of Inquest can only be amended in significant form by a decision of the High Court by way of judicial review. For those reasons, this claim was brought. It was the joint position of the parties that it would be in the interests of justice for the amendment to be made by the High Court.

The interested party, Roisin’s ex-partner, has been properly served with the proceedings but has played no part in them, as he did not at the inquest below.

Permission was granted in relation to ground 1 by His Honour Judge Gosnell by order dated 6^th November 2023. The parties agree that if I approve the consent order they have provided, ground 2 need not be pursued.

As required by the CPR, PD 54A, paragraph 16.1, a short agreed statement of the matters relied on as justifying the order has been filed. The task of the court in those circumstances is set out at paragraph 16.2. It is to review the documentation and make the order if satisfied that the order should be made.

I am entirely satisfied that that order should be made for the reasons I have set out: in summary, in order to reflect the evidence and the findings the Coroner not only made but intended to make, the Record of Inquest needs to be amended.

Revising the Record of Inquest in this fashion is an appropriate remedy: see, for example, R (Mowlem plc) v Avon Deputy Assistant Coroner [2005] EWHC 1359 Admin at [24], per Mr. Justice Wilson and Ministry of Defence v HM Coroner for Wiltshire & Swindon [2006] EWHC 309 Admin at [16], per the Divisional Court, comprising Lord Justice Richards and Mr. Justice Clarke.

For these reasons I order that the claim for judicial review succeeds on ground 1 which relates to the Record of Inquest. The wording of box 3 will be amended in the way set out in my order. The order will reflect that ground 2 has not been proceeded with given my agreement to the consent order drafted.

I conclude this short judgment by reiterating that at the heart of these proceedings is the claimants’ tragic loss; and for that I reiterate my condolences to them. I hope that the outcome of these proceedings is of some comfort to them and I am grateful to the legal representatives for their considerable assistance.