Case Report: R (On the application of Jada Bailey) v HM Senior Coroner for East London [2025] EWHC 1637 (Admin)

Jaden was an individual who had been killed on 8 January 2019. An inquest to his death was formally opened on 18 January 2019. The inquest process was then overtaken by the criminal proceedings which took place, and the inquest was adjourned on 2 April 2019. Ayoub Majdouline was convicted of Jaden’s murder and sentenced to life imprisonment with a minimum term of 21 years on 18 December 2019.

On 24 December 2019, the Coroner issued a certificate that the inquest was not to be resumed. The Claimant applied to the Coroner to resume the inquest in June 2023 and a decision not to resume the inquest was issued in a document dated 18 March 2024. Jaden’s mother, Jada Bailey (the “Claimant”), sought to judicially review that decision on three points:

• The decision not to resume the inquest gives rise to a breach of the procedural obligation under ECHR Article 2;
• The Coroner’s conclusion not to resume the inquest rested on two errors of law as to the likely utility of the resumed inquest; and
• The decision was contrary to a duty to investigate arising at common law (this was abandoned in submissions as there is no separate common law source of either power or obligation for a Coroner to investigate – they are statutory under the Criminal Justice Act 2009). This was then adapted that the Coroner had failed to have regard to relevant considerations, namely:
  • the public interest in holding an inquest;
  • the purpose pursued by sections 5(1) and (2) of the 2009 Act;
  • that an inquest can serve to allay any public concern arising from a death; and
  • the possibility of making a regulation 28 report.

The decision not to resume the inquest gives rise to a breach of the procedural obligation under ECHR Article 2

The Coroner had accepted the Claimant’s basic premise that there was an obligation to investigate under ECHR Article 2. In the usual course of inquests, the holding of an inquest discharges the investigative duty as required under the provisions of the 2009 Act. The Coroner in this case had considered that the investigative duty had been discharged already by the time the Claimant had sought to resume the inquest, as a Serious Case Review had been commissioned by the Safeguarding Children’s Board for Waltham Forest, published in May 2020.

The Claimant’s submitted that there were concerns regarding the scope and content of the SCR report; there were criticisms regarding the form of the investigation; the author of the SCR report lacked independence; the Claimant did not have sufficient opportunity to be involved in the SCR exercise; and it did not meet the requirement for public scrutiny. Further, following the SCR report, complaints raised about the conduct of the Metropolitan Police had not been properly addressed in an investigation by the Independent Office for Police Conduct.

As to the SCR report, Swift J commented:

It is readily apparent from the SCR report that it is a thorough and thoughtful consideration of all relevant matters. To my mind the SCR report is a highly impressive piece of work that should provide valuable assistance to all public authorities concerned. By identifying very clearly things they did and things they failed to do the SCR report ought both to promote accountability for what happened and to provide valuable guidance to those public authorities as regard their future conduct. Whenever considering a document such as this SCR report it will always be possible to point to further questions that could have been considered or further detail that could have been looked for. But that is not the test of whether the investigation that has been undertaken meets the requirement arising under article 2. In the circumstances of this case the investigation needed to consider the actions of the public authorities in Nottinghamshire and in London that had responsibilities that, if performed, would have served to safeguard C against the risk of falling victim to criminal exploitation. The SCR report, as written, evidences an effective investigation of the actions and omissions of those public authorities.

…

The purpose of an article 2 investigation is to consider what did happen; to establish a picture of past events. Often it will be readily apparent from findings on what did happen, what other steps should have been taken. That is so in the present case since it is clear from the SCR report that certain steps that were not taken should have been taken. But that is a by-product of the investigation.

Swift J considered that there was no principle reason why the SCR report, and the way in which the investigation had been conducted, was incapable of satisfying the article 2 duty to investigate. Swift J found that the author of the SCR report was independent and there was no suggestion that the investigation was not independent either. There was no requirement for an inquest to compel witnesses to give evidence or for certain documents to be provided, and so the argument that the SCR process did not do this had to fall away.

As to the lack of public scrutiny, Swift J held:

The requirement arising from article 2 for sufficient public scrutiny of either the investigation or its results or both, exists to ensure accountability, to promote public confidence in adherence to the substantive obligations arising under article 2, and to prevent any appearance of collusion or tolerance of unlawful acts. What is appropriate to meet these objectives is not fixed. There is no requirement that an investigation must be conducted through public hearings. I do not consider that the investigation that Mr Drew undertook was impaired by the absence of such hearings. Considered in the round, the SCR report identifies and then scrutinises the acts and omissions of the relevant public authorities.

Moreover, as to the lack of the Claimant’s involvement:

Given the factual circumstances… “I do not consider any of this shows that the Claimant was insufficiently involved in the investigation or lacked an effective opportunity to participate in and comment on the formulation of the SCR report. Rather, opportunities to participate were available from the outset of the investigation in early 2019 and, given the assistance available to the Claimant from the experienced and able solicitors who advised her, the opportunities to participate were real and substantial.”

The Coroner’s conclusion not to resume the inquest rested on two errors of law as to the likely utility of the resumed inquest

The Claimant submitted that the Coroner had failed to consider a narrative conclusion in their decision and their comments in relation to regulation 28 reports indicated a misdirection on the law.

As to the first point, Swift J remarked:

The suggested distinction between “short-form” and “narrative” conclusions that is the premise of this submission is a distinction without a difference. There is no material difference between a conclusion expressed using any of the terms listed in Note (i) and one that is in the “brief narrative” form anticipated by Note (ii). Each is intended to be descriptive: to describe the outcome of the inquest. For example, a conclusion of “unlawful killing” could be given either by simply using those words or through a narrative to the same effect.

The Coroner had referred to regulation 28 reports as ‘toothless’, and whilst Swift J considered that this was a rather colourful description; the Coroner had not misdirected himself on the law in relation to regulation 28 reports; and therefore this ground also failed.

Failure to have regard to relevant considerations

Swift J found that the Coroner did have regard to the possibility of making a regulation 28 report and that reading the decision in the round it had specifically considered and took the relevant considerations into account. This ground therefore failed.

Takeaways and practice points

The most interesting part of this decision is that the duty of the State to investigate does not have to be via the traditional inquest route and can be discharged via different avenues – there is no automatic right to an inquest. If other investigations have taken place in/around an incident one must take a holistic view of everything and consider whether it meets the article 2 duty; if so, there may not be a need for an inquest.

Bharat Jangra is part of the Inquests Team at Parklane Plowden. Bharat’s profile can be accessed here.