The coroner's court is neither a civil nor a criminal court, and the rules of procedure for those courts do not apply. The coroner's court is an inquiry into the circumstances of a death, and not an adversarial proceeding. The coroner's court is a court of record, and those records are public.
Legal authorities indicate that the coroner has discretion in determining what verdicts are to be left to the jury. There is no obligation on the coroner to put every possible verdict before the jury - only those supported by the main thrust of the evidence. According to one senior lawyer, the coroner is the alpha and omega of the coroner's court.
Judicial review of an inquest is generally applied for because one party thinks other verdicts should have been left to the jury, and/or that the verdict reached was not a reasonable one given the evidence.
Legal authorities also indicate that on an application for judicial review of an inquest, the judge would examine the evidence given at the inquest and determine whether it supported the verdict given, or specify what other verdicts - supported by the evidence - ought to have been left to the jury, and give his reasons.
In the application for judicial review of the Esfakis inquest by Dr. James Iferenta, the Chief Justice did not review any evidence. The Chief Justice made a determination of principle that the coroner could not leave a single verdict to the jury.
This is a precedent which now binds the coroner's court. The effect is that in every future inquest the coroner will be obliged to leave more than one verdict to the jury.
As of the end of November, 2008 the chief justice had given no written reasons for his ruling, and had not signed the order quashing the Esfakis inquest. What follows is a transcript of the unsigned ruling:
"The applicants in this case were given leave to move for judicial review by way of an order of certiorari quashing the summing-up and/or direction given by the coroner to a jury which returned a verdict, which verdict is in the prescribed form under the Coroner's Act, Chapter 56.
The challenge as framed and advanced by counsel for the Applicants raised a number of issues which would have invited the court's consideration and considered determination thereof, save for the fact which starkly appears from the record that after this extensive hearing involving a large number of witnesses over several adjournments as indicated in the juror's inquisition, the Coroner began his directions to the jury in this manner:
"If in my view as Coroner the facts in evidence point in one direction only, point towards one verdict and no other, then I am bound to direct that you arrive at that verdict...this case responds in one direction only. In those circumstances I have a responsibility to direct you to that verdict:
"Christopher Esfakis died from natural causes with a substantial and significant contribution by negligence on the part of Doctors Hospital medical and nursing staff in the management of his burn injuries."
The coroner then goes on to sum up to the jury the evidence, after which, presumably -- and I say 'presumably' because at the early stage of this hearing an adjournment was necessary in order for counsel to agree what constitutes the record -- presumably the verdict of the jury as stated in the inquisition was produced.
Counsel for the Respondent, although seeking to defend the decision of the Coroner to give a directed verdict to the jury as to the decision at which they should arrive was, to my mind, not surprisingly unable to cite authority for what to my mind would be a remarkable finding, and was left seeking to argue by analogy the position of a judge presiding in a criminal matter directing a jury in whose charge an accused person has been put to arrive at a verdict of acquittal, an analogy which clearly has no application in the instant case.
It seems to me that this fundamental error on the part of the Coroner makes it unnecessary for this Court on the present application, desirable though it might otherwise have been, to explore the several other issues which counsel for the Appellant urged upon the Court.
When a coroner's inquest is indicated and a coroner's jury empanelled, they are bound according to the oath that they take in embarking upon their duties as jurors, with the guidance of the Coroner in the usual manner of summarizing the evidence and directing them on the questions of law in a way not dissimilar to the task of a judge presiding in a criminal trial, to themselves arrive at a verdict.
The course taken by the Coroner in this case on the face of it means that the verdict was not that of the jury and, indeed, that is how counsel for the Respondent began his submissions in answer to the case for the Applicants.
In the result, the verdict of the coroner's jury is quashed and the matter is remitted for rehearing before a different Coroner"
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