Coroner thinks again

Freelance journalist successfully challenges secretive inquest

A coroner who refused to publish the findings of an inquest has reversed his position after a challenge by the media.

Crispin Butler, HM Senior Coroner for Buckinghamshire, announced last October that the inquest into the death of Graham Robert Whelan, 38, who died last year at his home in Wendover, would be “completed in writing” — without an oral hearing — unless reasonable objections were received.

Findings requested

That decision was not challenged. But Charlie Moloney, a local freelance journalist and media law trainer, wrote to the coroner asking for a copy of the ruling, his findings of fact and any documents referred to during the inquest.

Crispin Butler (L) and Charlie Moloney (R)

The coroner refused. Moloney was told:

The senior coroner has considered the request and we have liaised with the family to weigh up the interests of the family against any public interest in the circumstances of the death of Mr Whelan.

As far as the senior coroner was aware, the proposal to conclude the inquest in writing was notified on the council website and no objections or requests for a hearing in open court were received. The senior coroner maintains the view that it was appropriate to conclude the inquest in writing on this basis and that there was and remains no public interest in the circumstances. The family concur.

On this basis, the interests of the family are favoured over any change in the view as regards public interest in reporting the circumstances. There is no broader learning or public health benefit that would merit publicity in this case. There will be no post-inquest disclosure in response to this request.

Formal application

In response, Moloney made a written application to the coroner on 17 December 2024. He pointed to guidance issued by the chief coroner, which says:

The completed record of inquest should be treated by coroners as a public document. Some redaction may be necessary, for example the signatures of jurors (in all jury cases).

The press should be allowed to inspect the record of inquest or copy it or have a copy provided. A charge may be made for copying. In practice, journalists will usually photograph the document on their phone.

Separate guidance deals with inquests held in writing. This says:

To satisfy the requirement for open justice, basic information about the inquest in writing should be published in advance…

This will mean members of the public and press can find out that the inquest will be taking place in writing, and can make representations and/or request copies of documents, if desired.

A footnote confirms that coroners have powers to provide copies.

In the light of this guidance, Moloney submitted to Butler that his decision had been unlawful. The reporter told him:

This decision represents, in effect, an inquest being held in private. The outcome not being disclosed to the media means it will never be known to the public. That is, I would submit, an unprecedented decision.

Given the magnitude of that change, which would strike at the very heart of the principle of open justice, I would submit that unless there is some clear, unambiguous source of this power to hold a private inquest which the coroner can point to which makes this decision lawful then I would submit it is not lawful.

Coroner’s first ruling

The coroner issued his first ruling on 2 January. I am publishing it in full. He said:

There is no wider public health benefit or public learning or safety outcome to be gleaned from the specific circumstances of the death of Mr Whelan.

In contrast, the sensitivity of the circumstances (which are not set out in this ruling) are such that the only likely outcome from publicity is one of damage to the wellbeing of the remaining family…

In maintaining my view that, in this particular case, I am reasonable in exercising my discretion not to disclose the record of inquest in response to the formal request, I believe this is required in order to protect the family from any glare of publicity and that, as such, the right to respect for private and family life (article 8 [of the human rights convention]) should outweigh the right to freedom of expression (article 10).

This is the minimum required in order to protect the article 8 rights in this specific case.

Moloney then approached the Media Lawyers Association, whose members work mainly for newspapers, broadcasters and publishers. They took advice from Guy Vassall-Adams KC.

Letter before action

The barrister drafted a letter under the pre-action protocol for judicial review which Moloney sent the coroner on 14 February. This is also published in full, apart from the signature page.

The letter set out the facts, the law and the guidance — including new guidance on inquests in writing published on 1 January, the day before Butler’s ruling was delivered. This says:

When an inquest takes place in writing, the public and press lose the ability to attend to hear the evidence that would, in all other types of inquest, be read out in open court. Coroners therefore need to take steps to ensure that inquests in writing comply with the fundamental principle of open justice…

It is the chief coroner’s view that coroners should usually accede to requests for both the ruling and record of inquest, as the record of inquest should normally be treated as a public document and the ruling contains information that attendees would have heard in court if the mode of hearing had instead been a documentary inquest in court.

Coroners will need a strong justification for refusing to provide copies of the ruling to the public and press, given the otherwise secretive nature of an inquest in writing.

Moloney’s letter argued that Butler had made an error of law in applying the regulations and that he had also erred by reversing the burden of proof when balancing articles 8 and 10 of the human rights convention. The letter invited the coroner to think again, failing which the reporter would launch judicial review proceedings.

Coroner’s second ruling

Moloney received a response on 21 February. It said:

The senior coroner has completed his review of the post-inquest disclosure request in the context of the pre-action protocol letter, the 2025 coroner’s bench guidance and associated 2025 guidance all issued by the chief coroner.

In parts, this new guidance supersedes and replaces some of the previous guidance notes, in part this elaborates on or clarifies certain matters. In particular there is a clearer position expressed as regards post-inquest disclosure, the usual status of the record of inquest and the significance of this in the context of open justice where an inquest is concluded in writing.

Whilst the senior coroner maintains the view that each request would still fall to be considered on its merits, in applying the overall thrust of the new guidance the senior coroner is of the view that the record of inquest and ruling (which was in the form of a findings document in this case) can and should be disclosed in this case in response to a legitimate request by a bona-fide member of the press.

Those documents were then disclosed to Moloney.

Coroner’s findings

The findings document, dated 25 September 2024, recorded that Wheelan, a project manager who worked in electrical engineering, had failed to show up for work on a Monday morning last April. A family member went to his home, entered the upstairs bedroom and found him dead.

There were no physical or mental health issues, according to his GP. Toxicology demonstrated nothing of relevance. There were no concerns of any third-party or criminal involvement

“The clear, unfortunate, medical cause of death,” said the coroner, “was as a result of the compression of his neck with a ligature”.

Butler added:

Family and a friend also confirmed that Graham was a physically fit, quiet, private but happy person — potentially a bit isolated but there were no particular concerns about Graham intending to harm himself.

A family view was that this was a tragic but unintended incident, with which view the coroner concurs.

Record of inquest

The record of inquest said:

1. Name of deceased: Graham Robert Whelan.

2. Medical cause of death: compression of the neck by ligature.

3. When, where and how the deceased died: Graham Whelan was found deceased at home on 22 April 2024, having unintendedly died as a result of an act of suspension.

4. The conclusion as to the death: misadventure.

News report

Moloney’s report on the inquest was published by the Bucks Free Press yesterday.

Comments

Tragic though this case is and well-intentioned though the coroner’s motives clearly were, in my view the dangers involved in “an act of suspension” should never be hidden from public view.

The Media Lawyers Association said yesterday:

We welcome the senior coroner’s decision to review the initial decision and to rule in favour of disclosure.

There is a strong public interest in such documents being made available to the public and to the media under the open justice principle because it enables the public to understand the coroner’s findings and the circumstances in which people have died.

Moloney added:

The coroner’s initial ruling, if upheld, would have effectively represented the end of open justice in the coronial courts. If coroners could pick and choose which cases the media were entitled to report by merely deciding to hold an inquest “in writing” then that would — to paraphrase Lord Shaw of Dunfermline in the 1913 case of Scott v Scott — shift the foundations of freedom of expression from the rock to the sand.

I remain concerned that significant pressure had to be brought to bear before this result could be achieved. It was only when the prospect of judicial review was raised that the documents were disclosed. Other journalists facing a similar situation in future may be entirely deterred from reporting if they face such an impediment and that could stymie the flow of important information into the public domain.