Attorney general ‘sorry’
Four-year inquest delay blamed on administrative error by former government
The High Court has expressed “concern” about a delay by the attorney general’s office of more than four years in authorising a new inquest into the apparent suicide of a young man whose death might have been prevented.
Under section 13 of the Coroners Act 1988, a new inquest may be ordered by the High Court in the interests of justice when, for example, new facts are discovered. But an application to the court may be made only with the authority of the attorney general.
This authority is known as a “fiat”, from the phrase fiat justicia — let justice be done.
The senior coroner for the western district of West Yorkshire asked the then attorney general Suella Braverman for her fiat on 27 February 2020. It was not granted by one of her successors, Victoria Prentis, until 15 May 2024.
High Court proceedings were launched by the senior coroner on 24 June 2024 but took another year to be resolved. An unopposed hearing took place at the beginning of this month, after which Lord Justice Jeremy Baker and Mr Justice Butcher delivered a judgment on 3 July ordering a new inquest.
The inquest
Leonardo Pronesti, formerly known as Liam Christopher Shaw, was 21 when he died on 25 December 2017. He had a history of mental health difficulties and self-harm with suicidal ideation. Pronesti had been under the care of mental health services since the age of 15.
On 21 December 2017, a package had been left at the Ravensleigh Resource Community Mental Health Unit in Dewsbury. It was partly open and the nurse who examined it could see papers with Pronesti’s name and indications that he might be suicidal. The nurse alerted the police who made checks.
Later that day, Pronesti was admitted Pinderfields Hospital in Wakefield with a suspected overdose of prescribed medication.
After he had denied having had any suicidal intent, he was discharged from hospital on 22 December.
On 25 December, he failed to join his mother for Christmas. She called the police who went to his home and found him dead. A doctor gave the cause of death as “asphyxia (hanging)”.
Evidence was collected for an inquest. But the assistant coroner who conducted it in August 2018 was never shown the package of documents left at the mental health unit. He found insufficient evidence to establish that Pronesti had intended to take his own life.
Later that year, after enquiries by Pronesti’s family, his package of documents was found in a drawer at the Bradford coroner’s officers’ office. It contained many references to suicide. The senior coroner wanted to hold a new inquest and applied for the attorney general’s fiat.
Giving judgment last week, the High Court said it could well understand that the assistant coroner would probably have recorded a verdict of suicide if he had seen those documents.
He might also have had to consider “whether and to what extent both the South West Yorkshire Partnership NHS Foundation Trust and the West Yorkshire Police had complied with an operational duty owed to the deceased to protect his life under article 2 of the European Convention on Human Rights”.
And it was arguable that the documents delivered to the mental health unit, presumably by Pronesti, should have been investigated further at the time.
For these reasons, the judges agreed that a new inquest was necessary and desirable.
They added two more comments:
Firstly, to record our gratitude for the clarity of the submissions which were made by Alison Hewitt on behalf of the claimant.
Secondly, to record our concern about the delay which was occasioned by the attorney general in granting the fiat in this case, which we anticipate will not only have caused further unnecessary anxiety to the deceased's family but may have an adverse impact on the quality of the evidence available to those responsible for conducting the fresh investigation and fresh inquest into the death of the deceased.
In these circumstances, a copy of this judgment will be sent to the attorney general.
Response
A week ago, I asked the attorney general’s office for a response. I was told yesterday that the delay — granting the fiat took more than 50 months — was caused by an “administrative error”.
I understand that the attorney general’s office has now introduced a centralised tracking system to monitor the progress of such cases. Senior officials receive monthly reports. And although there are no statutory deadlines, applicants and interested parties are asked to make any representations within a four-week timescale.
A spokesperson for the attorney general Lord Hermer KC told me:
The delay in this case should not have happened and we are sorry for the impact it has had on Leonardo Pronesti’s family and friends.
This administrative error occurred during the previous government. The way the attorney general’s office handles applications for fiat has changed significantly in the time since and we continue to monitor our processes so delays don’t happen again.
Comment
It’s understandable that the job of filtering out unmeritorious requests for new inquests should have been given by parliament to the attorney general. But when an application for a fiat is made by the senior coroner for the relevant area, there can surely be little or no justification for refusing it.
Further delay was caused to the senior coroner’s High Court claim because he couldn’t work out who the defendant should be. The obvious answer is the assistant coroner whose verdict was being challenged.
I make these observations after reading an excellent commentary on the case published on Tuesday by Bridget Dolan KC of Serjeants’ Inn chambers, who’s a specialist in this area of law and practice.
Writing on the UK Inquest Law Blog, Dolan said:
What makes this simple and uncontested case rather remarkable is how long it has taken for the right thing to happen and for an order for a fresh inquest to be made. The new evidence was discovered and put before the coroner within six months of the initial inquest concluding. Yet it was a further six years before that fresh inquest could be granted by the High Court.
Most (but by no means all) of the delay seems to have been occasioned by delays at the attorney general’s office…
Baron Hermer may now be rather peeved to be receiving a nudge from the High Court about something that was clearly not his own doing — but if the judicial nudge results in section 13 fiat applications being speeded up in future this can only be a good thing…
Even when the process runs smoothly, a fiat can take months to obtain. The delay inherent in the process of seeking a fiat merely extends the waiting for families and increases administrative time and costs for coroners.
This case provides further support for a revision of the legislation so that a senior coroner seeking to overturn an inquest in their own jurisdiction would no longer need the attorney general’s permission before they can bring a section 13 claim before the High Court.
That sounds to me as if it would be a very wise reform. I wonder how long we shall have to wait for it to be put into effect.
As to what Joshua supports as a seemingly sensible amendment, do I hear,”when Parliamentary time allows”?
This dreadful delay has caused terrible suffering to the family who want answers to the question of how their beloved son was not stopped from killing himself. It's shocking that Braverman allowed this delay to happen, caused this delay in fact. This is why lawyers should stick to law and not indulge their political ambitions unless they cease to practice law.