Does the word ‘poor’ denote negligence?
An analysis of R (Wells Rugby Football Club Ltd and Taunton Rugby Football Club Ltd) v HM Senior Coroner for Somerset [2026] EWHC
The judgment arose from an oral permission hearing for judicial review proceedings.
The facts
The Deceased had attended a youth rugby match as a spectator when she was struck on the head by a rugby ball that had been kicked from the main pitch. The Deceased suffered a severe head injury and was taken to hospital for treatment. She suffered a severe head injury but she also had a pre-existing blood disorder (aplastic anaemia), which made her vulnerable to the consequences of trauma. Unfortunately, despite undergoing treatment, her condition deteriorated and she died.
An inquest was held and the Senior Coroner gave the following narrative conclusion:
‘Accidental death contributed to by poor supervision and spectator safety management.’
The Grounds for Judicial Review
Both rugby clubs sought judicial review of the conclusion. They advanced five arguments:
- The use of the word ‘poor’ suggested a finding of fault and/or civil liability.
- The conclusion was not neutral. The word ‘poor’ expressed an opinion.
- The Senior Coroner failed to conduct an adequate investigation.
- The Senior Coroner refused to allow questioning on the objective standards of spectator management, and this amounted to procedural unfairness.
- The findings were unreasonable and could not be reached on the evidence.
The Claimants drew the Court’s attention to Sections 5 and 10 of the Coroners and Justice Act 2009 which prohibits conclusions that determine criminal or civil liability and the case of R v HM Coroner for North Humberside and Scunthorpe ex p Jameson [1994] which states that coroners should not attribute blame or determine civil liability, but may make factual findings as to how the death occurs.
There was further consideration of the Chief Coroner’s Guidance No.17 which advises ‘In a non-article 2 case, a narrative conclusion should be a brief, neutral, factual statement; it should not express any judgment or opinion’. It was noted by the Court that the guidance also states ‘the difference in some cases may be slight and not much more than a matter or words’.
The Senior Coroner also provided a detailed response in respect of the Claimant’s grounds and rejected that there was any expression of civil liability and/or an opinion. She stated that the conclusion was based upon the witness evidence regarding spectator management.
The Decision
Mr Justice Kimblin rejected that argument that word ‘poor’ denoted a finding of negligence and/or civil liability. In his opinion, whilst the word ‘poor’ was ‘unusual’ it did not go so far as to establish civil liability.
Mr Justice Kimblin also rejected the argument that the conclusion was unlawful because it expressed an opinion. He noted that the Senior Coroner had heard evidence on this issue and therefore she was entitled to make a factual finding that these arrangements were poor. Mr Justice Kimblin acknowledged that the dividing line between factual findings and opinion is ‘not always easy to identify’, but he was satisfied that the Senior Coroner had made a factual determination rather than expressing an opinion.
Mr Justice Kimblin also considered whether there had been any procedural unfairness. In his opinion, there was sufficient evidence before the Senior Coroner regarding risk, the arrangements that had been made and what could have been done better. Mr Justice Kimblin was therefore satisfied that there no need for further evidence as to the objective standard of spectator management.
Comment
The case provides a useful reminder of the distinction between a finding of fact and a finding of negligence/fault or opinion. As commented in the judgment this can often be ‘a difficult line for coroners to tread’ and the choice of words in the narrative conclusion are critical. It is however important to look at the words in context, rather than isolation. In this case, the word ‘poor’ was acceptable in the context of a factual finding as to the standard of the arrangements that had been made. As emphasised in the judgment, these arrangements may be described as ‘poor’, but this may fall short of a legal finding of negligence.
