Coroners ~ Duggan case ~ reports

It is reported that the Coroner (His Honour Judge Keith Cutler) who presided over the Duggan Inquest is to invite the Duggan family to 'help shape police gun policy' - The Guardian 12th January 2014.  The judge, who is preparing recommendations on firearms procedure for the home secretary after issues raised at the inquest, described his decision to consult the family as "unusual, perhaps unique" but the right thing to do to achieve transparency.

The Coroner will be in the process of preparing what is now referred to as a 'Prevention of Future Deaths' report - previously known as a 'Rule 43' report. 


When is there a duty to make a report?

Coroners and Justice Act 2009 Schedule 5 (paragraph 7) states:

Action to prevent other deaths
7(1) Where -

(a) a senior coroner has been conducting an investigation under this Part into a person's death,
(b) anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and
(c) in the coroner's opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances,

the coroner must report the matter to a person who the coroner believes may have power to take such action.

(2) A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it.

(3) A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner.

Reports:

Regulation 28 of the Coroners (Investigation) Regulations 2013

Report on action to prevent other deaths

(1)  This regulation applies where a coroner is under a duty under paragraph 7(1) of Schedule 5 to make a report to prevent other deaths.

(2) In this regulation, a reference to “a report” means a report to prevent other deaths made by the coroner.

(3) A report may not be made until the coroner has considered all the documents, evidence and information that in the opinion of the coroner are relevant to the investigation.

(4) The coroner—

(a) must send a copy of the report to the Chief Coroner and every interested person who in the coroner’s opinion should receive it;

(b) must send a copy of the report to the appropriate Local Safeguarding Children Board (which has the same meaning as in regulation 24(3)) where the coroner believes the deceased was under the age of 18; and

(c) may send a copy of the report to any other person who the coroner believes may find it useful or of interest.

(5) On receipt of a report the Chief Coroner may -

(a) publish a copy of the report, or a summary of it, in such manner as the Chief Coroner thinks fit; and

(b) send a copy of the report to any person who the Chief Coroner believes may find it useful or of interest.

Responses to reports:

Regulation 29 deals with responses to such reports.  The response to a report must contain - (a) details of any action that has been taken or which it is proposed will be taken by the person giving the response or any other person whether in response to the report or otherwise and set out a timetable of the action taken or proposed to be taken; or (b) an explanation as to why no action is proposed.   On receipt of a response to a report the coroner - (a) must send a copy of the response to the report to the Chief Coroner; (b) must send a copy to any interested persons who in the coroner’s opinion should receive it; and (c) may send a copy of the response to any other person who the coroner believes may find it useful or of interest.

Publication of reports:

The Regulations provide only that reports and responses to reports MAY be published either completely or in summary form.   A possibility that a report / response may not be published remains.  Representations can be made to the Coroner with regard to publication and it is a matter for the Chief Coroner to decide whether there should be any restrictions on the release or publication of the response.   

The Duggan Inquest met with protest by individuals present both inside and outside the High Court.  The determination of the jury has met with some criticism and, at the time of writing, it appears that a judicial review is under consideration.

The controversy surrounding the case may be a factor in favour of publication of, at least, a summary report.  However, there will be factors pointing the other way.  For example, the Police might choose to oppose publication on the basis that firearms training methods should not be made available because of the possibility of informing criminal elements of the methods in use.

The Guardian's article notes:  'The judge said he had informed all parties of his decision and the police had asked to hear what others had to say first before making their own submissions.'


The 2013 regulations came into force on 25th July 2013.

Note 14 October 2019 - The Guardian 10 October 2019 - Mark Duggan shooting: family settle high court claim against Met