Neutral Citation Number: [2017] EWHC 3117 (Admin)
Case No: CO/1364/2017
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
ADMINISTRATIVE COURT

Royal Courts of Justice
Strand, London, WC2A 2LL

Date: 05/12/2017

Before:

THE RT. HON. LORD JUSTICE LINDBLOM
THE HON. MRS JUSTICE NICOLA DAVIES DBE
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Between:

	ANN POWER	Claimant	
	
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	HER MAJESTY’S SENIOR CORONER FOR INNER NORTH LONDON	Defendant	
	
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	(1) THE COMMISSIONER OF POLICE
OF THE METROPOLIS
(2) STEPHEN COLLIER	
Interested Parties	

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Mr Leslie Thomas QC (instructed by Hickman & Rose Solicitors) for the Claimant
Mr Paul Stagg (instructed by Directorate of Legal Service Metropolitan Police Service) for the First Interested Party
No representation or appearance by the Defendant or Second Interested Party

Hearing date: 21 November 2017
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Judgment Approved
Mrs Justice Nicola Davies: 
1.	On 16 March 2017 the claimant issued proceedings pursuant to section 13 of the Coroners Act 1988 (“the 1988 Act”) seeking an order:
i)	That the inquest touching upon the death of her husband, Mr Onese Power, be quashed; and
ii)	A direction that a fresh inquest be held.  
A Fiat was granted by the Attorney General’s office on 7 February 2017 authorising the claimant to make the application.  
2.	The deceased, Onese Power, was born on 2 May 1946.  He was married to the claimant and they had three sons.  On 6 June 1997 the deceased was disqualified from driving for six months.  At approximately 10:45 on 17 August 1997 the deceased was driving a Kawasaki motorcycle along Camden Road, NW1.  He was travelling at an estimated speed of 60mph along a road with a speed limit of 30mph.  He was observed by PC Collier, who was driving a liveried Vauxhall Cavalier, registration number N49 OUW and PC Heatley, who was the operating officer in the car.  PC Collier and Heatley made efforts to stop the deceased.  The Court was informed that the trigger for their efforts was the excessive speed of the motorcycle.  A pursuit ensued over a distance of approximately three miles, which lasted approximately three minutes.  At a left hand bend where Royal College Street, NW1, meets St Pancras Way and Farrier Street, the deceased’s motorcycle left the carriageway and struck a bollard in the central reservation, as a result of which the deceased sustained fatal injuries.  It is the claimant’s case that the central issue is whether there was contact between the police car and the motorcycle prior to the collision with the bollard.
3.	The inquest into the death of the deceased was held at St Pancras Coroners’ Court on 18 February 1998 before a jury who returned an open verdict.  The claimant was not legally represented at the inquest.
4.	The claimant submits that a new inquest should be ordered on three grounds:
i)	Irregularity of proceedings
The claimant did not receive disclosure of witness statements prior to the inquest despite a request for the same.  Neither the claimant nor the jury were aware that PC Collier and PC Heatley had given identical statements five days following the fatal incident.  A relevant witness was unable to attend due to ill health;
ii)	Insufficiency of inquiry
There were failures:
a)	to test the police vehicle at the speed at which it was travelling at the time of death in order to replicate the tyre marks found at the scene;  
b)	to forensically examine the damage to the police vehicle which could have been caused by contact with the motorcycle driven by the deceased.
iii)	New evidence has become available which was not known at the time of the original inquest.
5.	The defendant and the first interested party have filed Acknowledgements of Service and have indicated that they take a neutral stance in respect of this application.  The second interested party has informed the solicitor of the first interested party that he is not seeking separate representation for the purpose of this hearing.  At the hearing the first interested party provided written and oral observations upon the application but maintained the stance of neutrality.  Two witness statements were submitted, one from DS Tina McLeod dated 6 November 2017 which records that the motorcycle was exported on 7 August 2009 and the police vehicle was stolen on 22 October 1998.  A statement from Detective Chief Superintendent Paul Rickett provided updated information in respect of the Metropolitan Police Service Pursuit Policy first published in 1997.  
6.	In written submissions the claimant and the first interested party had raised the issue of the applicability of Article 2 ECHR.  At the hearing both parties agreed that section 13 of the 1988 Act provided the relevant relief, so the arguments in respect of Article 2 were not pursued.

The law
7.	The Coroners Act 1988:
“13 Order to hold investigation.
(1) This section applies where, on an application by or under the authority of the Attorney-General, the High Court is satisfied as respects a coroner (“the coroner concerned”) either—
… (b) where an inquest or an investigation has been held by him, that (whether by reason of fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, the discovery of new facts or evidence or otherwise) it is necessary or desirable in the interests of justice that an investigation (or as the case may by, another investigation) should be held.”
8.	The duty of a coroner was identified by Sir Thomas Bingham MR (as he then was) in R v HM Coroner for North Humberside and Scunthorpe (ex parte Jamieson) [1995] QB 1 at 26:
“It is the duty of the coroner as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the relevant facts are fully, fairly and fearlessly investigated.  He is bound to recognise the acute public concern rightly aroused where deaths occur in custody.  He must ensure that the relevant facts are exposed to public scrutiny, particularly if there is evidence of foul play, abuse or inhumanity.  He fails in his duty if his investigation is superficial, slipshod or perfunctory.  But the responsibility is his. He must set the bounds of the inquiry.  He must rule on the procedure to be followed.  His decisions, like those of any other judicial officer, must be respected unless and until they are varied or overruled.”
9.	The power contained in section 13(1)(b) is stated to be in very broad terms.  A fresh inquest may be ordered where there is a possibility of a different verdict.  In R (on the application of Sutovic) v HM Coroner for North London [2006] EWHC 1095 (Admin) per Moses LJ at [54-55]:
“54. The power contained in section 13(1)(b) is stated in very broad terms.  The necessity or desirability of another inquest may arise by reason of one of the listed matters ‘or otherwise’.  Notwithstanding the width of the statutory words, its exercise by courts shows that the factors of central importance are an assessment of the possibility (as opposed to the probability) of a different verdict, the number of shortcomings in the original inquest, and the need to investigate matters raised by new evidence which had not been investigated at the inquest: see Re Rapier [1988] 1 QB 26, 34-35, 37H-38A, 39 per Woolf LJ and Simon Brown J; R v HM Coroner, Lincoln, ex p Hay 19 February 1987; R v HM Coroner, Coventry, ex p O'Reilly Times Law Reports 3 April 1996; and Re v Assistant Deputy Coroner for the Northern District of London ex. p Bloom [2004] EWHC 3071 (Admin).  …
55. ... In cases in which the court is satisfied that a different verdict is not possible or doubts that it would be, the fact that the deceased died in custody may be ‘a compelling additional factor’ (R v West Sussex Coroner, ex p Homberg (1994) 158 JP 357, per Simon Brown LJ Transcript 26 January 1994, page 37) in concluding that a further inquest is necessary or desirable in the interests of justice.  This is because of the need (see paragraph [37] above) in such cases for an investigatory regime which will not only expose past violations of obligations under Article 2 but also promote measures to prevent or minimise the risk of future violations.  The lapse of time since the death is a factor that has generally been seen as a factor against ordering a further inquest (see ex p Homberg and Re Tabarn 20 January 1998 (Div Court), per Simon Brown LJ Transcript page 10) but this is not always so: see Nicholls v HM Coroner for the City of Liverpool [2001] EWHC (Admin) 922, paragraphs 49-50, 59 per Sullivan J.  In R v West Sussex Coroner ex p Edwards [1991] 156 JP 186, 190 it was stated that a new inquest may be ordered even if there is a high probability that the verdict would be the same.”
10.	The principles identified in the authorities, identified in paragraphs 8 and 9 above, are of general application and are not confined to particular types of fatalities e.g. deaths in police custody.
11.	Insufficiency of inquiry includes a failure by the Coroner properly and adequately to explore the circumstances surrounding the death and a failure to call sufficient evidence about the cause of the death, Howlett v HM Coroner for Devon [2006] EWHC 2570 at [17-20].  
12.	The scope of the investigation is not limited to a simple factual question as to the cause of death.  There is a broader public duty to seek out and record as many facts concerning the death as the public interest requires, R v South London Coroner ex parte Thompson [1982] 126 SJ 625, and to assuage public anxiety, Assistant Deputy Coroner for Inner West London v Channel 4 Television Group [2008] 1 WLR 945 at [7-9].
13.	The issue is whether the interests of justice make a further inquest either necessary or desirable.  HM Attorney General v HM Coroner of South Yorkshire (West) & Anor [2012] EWHC 3783 (Admin) per Lord Judge, Lord Chief Justice at [10]:
“The single question is whether the interests of justice make a further inquest either necessary or desirable.  The interests of justice, as they arise in the coronial process, are undefined, but, dealing with it broadly, it seems to us elementary that the emergence of fresh evidence which may reasonably lead to the conclusion that the substantial truth about how an individual met his death was not revealed at the first inquest, will normally make it both desirable and necessary in the interests of justice for a fresh inquest to be ordered.  The decision is not based on problems with process, unless the process adopted at the original inquest has caused justice to be diverted or for the inquiry to be insufficient.  What is more, it is not a pre-condition to an order for a further inquest that this court should anticipate that a different verdict to the one already reached will be returned. If a different verdict is likely, then the interests of justice will make it necessary for a fresh inquest to be ordered, but even when significant fresh evidence may serve to confirm the correctness of the earlier verdict, it may sometimes nevertheless be desirable for the full extent of the evidence which tends to confirm the correctness of the verdict to be publicly revealed.”

Ground One: Irregularity of proceedings
14.	Prior to the inquest the claimant requested the release of statements made in relation to the circumstances surrounding her husband’s death.  By a letter dated 29 January 1996 Chief Inspector P McRory responded to the claimant’s request in these terms:
“…I have to inform you that I have been instructed that the statements cannot be released to you.  Apparently, there are legal reasons for this decision which relate to the position of a coroner’s inquest within the British Judicial System.
All evidence which the coroner considers necessary to establish the cause of your husband’s death will be heard in public at his court and consequently you will be made aware of the circumstances involved.  Should he/she decide that some evidence should be read you will be supplied with a copy of the evidence of the hearing. 
I am sorry to have to disappoint you.  May I suggest that it might be appropriate for you to seek legal advice about representation at the inquest…”
15.	PC Collier recorded a statement on 17 August 1997 following the incident, PC Heatley did not.  On 22 August 1997 PCs Collier and Heatley made statements which are identical save for a few words which make no contextual difference to the substance.  At the time of the inquest neither the claimant nor the jury were aware that the statements were identical, and neither officer was asked questions about the similarities in their statements.  It is the claimant’s case that had she been legally represented in 1998 it is inconceivable that a request for the officers’ statements in advance of the inquest would have been refused.  More significantly, had disclosure not taken place prior to the hearing, when the officers gave their evidence and refreshed their memories from their witness statements, an advocate representing the claimant would have been permitted to see the statements.  
16.	In 1998 it would be usual for the Coroner to have the statements, and the Coroner would lead the questions using the statements as the basis for the same.  It is submitted that either the Coroner should have asked, or an advocate on behalf of the claimant who had seen the statements would have asked, how it was that the statements were so similar, how they had been compiled, and, as they were written five days after the accident, whether there was any degree of after the event reconstruction.  All of this was relevant not only to the issue of the fatal accident but also to the question of whether the police’s pursuit of the deceased’s motorcycle was dangerous.  It is clear from the questions asked at the inquest that the timing, sequencing, distance and speed of both vehicles were of importance.  The transcript of the radio communication between the operator and the police motor vehicle known as November 1 does not contain the amount of detail of the pursuit in terms of timing, sequencing, distance and speed which is found in the officers’ statements.  The transcript is a contemporaneous record of radio communication.  Had this document been available to the claimant or her legal representative at the inquest it could have provided a basis to test the veracity and credibility of the evidence of each police officer.  The claimant contends that the failure to disclose the statements and the Coroner’s failure to address the issue of the similarities in the statements, critically the issue of credibility which could flow from them, provide a basis for the Court to find that there was an irregularity in these proceedings.  

Witness Adele McDine
17.	Miss McDine, an independent witness, made two statements, dated 24 August 1997 and 12 September 1997.  She was walking home along St Pancras Way, NW5, saw a police car coming towards her, it was followed by four other police cars all with flashing lights and sirens.  The statement records:
“Shortly after they passed me I heard the sound of squealing brakes and the dull thud of a fast moving vehicle hitting a body.  I looked back to see what had happened, the first police car had stopped and I saw a police officer get out and lift a man from the road.  The other police vehicles were having to brake very sharply to avoid hitting the first police car.  I thought they were all going so quickly there was going to be a multiple accident…”
In her second statement Ms McDine gives further detail of the matters contained in the first statement.  
18.	At the inquest Chief Inspector Patrick McRory is recorded as saying “These are the statements of Miss Adele McDine”.  It would appear that they were read but the transcript does not contain the contents of the statements.  In her summing up to the jury the Coroner refers to documentary evidence being admitted and includes what is described as “a statement from Miss McDine” it being said that she was too ill to attend.  Mrs Power received no notice prior to the inquest that Miss McDine could not attend.  The claimant contends that had she been legally represented it is likely that on learning of Miss McDine’s inability to attend an adjournment would have been sought.  The evidence of this witness was relevant to speed, the sound of braking and whether or not contact was made between the motorcycle and the police vehicle.  She was an important witness.  The claimant was not afforded a proper opportunity to consider and test her evidence.  In the absence of legal representation, no consideration was given to adjourning the proceedings to permit the presence of Miss McDine.  This ground demonstrates a further irregularity in the original inquest.  

Evidence from three witnesses
19.	Disclosed are unsigned Proofs of Evidence of three witnesses, all of whom were living in Royal College Street.  Two heard the sound of the chase but looked out after the deceased had hit the bollard.  A third looked out immediately before the collision.  The witness saw a police car following a motorcycle on St Pancras Way.  She saw the impact, the motorcycle rider hit the first bollard, roll over three or four times in the road, finally becoming stationary next to the second bollard.  
Ground Two: Insufficiency of inquiry. 
A failure to conduct forensic tests on the skid marks and the damage to the police vehicle.  
20.	PC Devlin was the first traffic officer to arrive at the scene.  He noted that there were marks left on the road surface by the motorcycle that extended approximately sixty metres.  He noticed skid marks approximately ten metres in length extending from the police vehicle.  
21.	PC Martin McCarthy, a road traffic accident investigator made a statement dated 30 October 1997.  He arrived at the scene at 11:30am and found a series of marks consistent with being made by a motorcycle.  The vehicle had been travelling south-eastwards towards the left bend at the onset of the incident.  He found a single mark following the line of the nearside curb, close to the crown of the road in Royal College Street.  It continued towards St Pancras Way crossing over the white zigzag lines at the crown of the road, on the southbound approach to the pedestrian crossing on the northern end of the central island.  It continued in a straight line towards the central island, over zigzag lines, the locked wheel tyre mark became wider and separated into two distinct marks as it neared the curb of the centre island.  The marks ended against the curb of the centre island, which was 5.8 metres from the end of the single mark.  From impact from the curb of the central island the solo motorcycle was close to laying on its side.  Slide marks ran to the final position of the cycle.  PC McCarthy found marks on the bollard at the southeast end of the central island consistent with impact by the motorcycle or motorcyclist.  
22.	In order to calculate the speed of the motorcycle just before the moment of impact PC McCarthy used the length of the long tyre mark and the length of a slide mark by the motorcycle after it had fallen on its side.  He assessed the speed of the motorcycle at the commencement of locked wheel braking as 73mph.  
23.	The police vehicle was facing southeast in the offside lane of St Pancras Way parallel with the curb of the central island and 1.6 metres east of it.  The vehicle was across the gap in the centre island level with Farrier Street.  There were locked wheel marks under the police vehicle and continuous from it to the northeast.  It was the opinion of PC McCarthy that the marks were not the same track width as the police car and were not made by it.  At the time of the inquest PC McCarthy was on long term sick leave.  He was not called to give oral evidence.  PC Lamb had worked with PC McCarthy on the case and he went with him to the scene on the day following the accident.  
24.	PC Lamb gave evidence of marks found on the police vehicle.  Three areas of damage, not recorded in the log book, were present:
i)	Mark one – white scuff marks 87-90 cm from the ground on the edge of the offside door mirror;
ii)	Mark two – a long black rubbery mark on the front offside door 76-81 cm from the ground and travelling 40 cm from the rear of the door mirror;
iii)	Mark three – damage to the side and front of the bumper at the front offside corner, 43 cm from the ground.  
PC Lamb stated that Mark two was a typical scuffmark from a motorcycle handlebar grip but discounted it as having been caused by the motorcycle of the deceased as the vehicle did not have grips made of rubber, they were metal.  He stated that the police vehicle had been in contact previously but by another motorcycle.  He believed that the contact, at any sort of speed, would cause the motorcycle rider to lose control.  No forensic tests had been carried out to identify if the marks were or could have been made by contact with the deceased’s motorcycle.  No photographs were taken of the marks.  Given the claimant’s contention that there was contact between the two vehicles, she submits that forensic tests should have been performed to ascertain if the marks represented contact between the two vehicles.  
25.	PC Lamb did not see the tracks on the road which could have been left by the police vehicle.  He said that the vehicle was fitted with antilock braking.  He tested the police vehicle at a speed of 30 to 40 mph and found that it did not leave any skid marks.  It is the claimant’s case that this test did not replicate the higher speed at which the police vehicle was travelling and thus its findings are of little, if any, evidential value.  
26.	Mr David Turner of the Forensic Science Services Metropolitan Laboratory gave evidence of having checked the calculations of PC McCarthy.  He stated the conclusion of the motorcycle’s speed of 73 mph was a conservative estimate.  The mark on the road, made by the motorcycle, was a braking mark, it was not an acceleration mark.  The mark, 64 metres in length, represented a speed of 73 mph at the start of the mark.  As the motorcycle slid down the road for 21.5 metres it was losing speed.  

Ground Three: New evidence.
27.	Dr Searle, an expert in road accident analysis, provided a report dated 21 April 1999.  He disagreed with the opinion of PC Lamb that the marks on the police vehicle did not represent contact with the deceased’s motorcycle.  He concluded that the tyre marks left by the police vehicle were not locked wheel skid marks but were curve marks made under heavy braking combined with cornering.  His conclusions as to the accident were that Mr Power:
“…positioned himself near to the crown of the road with a view to smoothing out the bend…  It would appear that PC Collier has attempted to overtake on the nearside.  Because of the presence of the Audi car, that overtaking necessitated PC Collier going extremely close to the motorcycle.
Because of the Police car right alongside, Mr Power was unable to lean his motorcycle in order to take the bend.  When he attempted to lean his motorcycle, a contact occurred between the handlebar and the door of the Police car.  Unable to lean over and negotiate the bend, Mr Power applied heavy braking, to mitigate what was by now an inevitable spill.  However he ran wide, mounted the kerb and struck the bollard. 
Meanwhile the police car, to the nearside of the motorcycle, was also braking.  At the last, PC Collier brought his car to a stop by a combination of swerving and braking.  No marks were left under straight line braking but they were during the final swerve.”
28.	These conclusions directly contradict the evidence of PCs Collier and Heatley who maintain they were behind the motorcycle when it lost control.  They deny any contact between the motorcycle and the police vehicle.
29.	In 2004 as a result of unrelated matters a review was carried out by the CPS in respect of work done by Mr David Turner.  A written report by Mr Terrence Cox dated 9 March 2004 reviewed the statement made by Mr Turner in respect of this fatal accident.  Mr Cox’s comments on the statement from Mr Turner are in these terms:
“Overall an unusual statement from DFT.
I find the statement of DFT, in all the circumstances, to be remarkably short.  Only 10 lines actually relate to the case in question.  He says the mark left by the motorcycle tyre (when he may have meant tyres in the plural) is NOT typical of a locked wheel mark, although wear on the tyres (and this time he does use the plural) is indicative of heavy braking.
DFT goes on to say the co-efficient of friction employed by Constable McCarthy in relation to the slide of the motorcycle is reasonable.  Ends by asserting the marks to be indicative of speed of about 73 mph for the motorcycle as it entered the bend.
I would have preferred to understand some of the reasoning behind his assertions.  ”
30.	Later in the report Mr Cox states:
“Comment:
…Constable McCarthy used an assumed co-efficient of friction for the sliding motorcycle.  I appreciate there would have been some difficulty in establishing accurate co-efficients as the machine slid across more than one surface but it appears a drag test on the tarmac of the main carriageway would have been applicable to over half the distance of the slide and would have informed us better on the appropriateness of any assumptions to be made about the co-efficient for the remainder of the slide on the footpath area. 
Under the circumstances one might have expected more extensive photographs of the scene, of the marks and of the vehicles.  As the photographs that were taken show skid marks apparently coming from the police car I would have liked to see photographs of the measurements of the vehicle track width which proves they did not come from that vehicle.  Indeed Constable Devlin, the first traffic officer upon the scene mentions the skid marks left by the patrol car which was still in situ.  If it was difficult for an experienced traffic officer at the scene to determine they did not come from the police vehicle those of us working from the photographs might be forgiven some scepticism.  
Both vehicles were examined by Constable Lamb.  In a case such as this photographs of both vehicles would have been of assistance.  I should have liked to see the marks on the patrol car and the metal counterbalance weights on the motorcycle handle bars.  
I would have like to see the general presentation of the police vehicle which drew adverse comment from Constable Lamb.  I would have liked to be assured that the brake light on the motorcycle was or was not working.  Two police officers followed that motorcycle for several miles yet neither recalls at any time seeing its brake light come on.  Why.  As inappropriate braking seems to have been the undoing of Mr Power I should very much like to understand whether, depending upon how far behind the motorcycle they were, the officers should have seen the brake light come as the motorcycle entered the fatal bend and when the rider released the brakes.  
I am uneasy about this whole incident.
In all the circumstances I feel the MPS may leave itself exposed to criticism if it does not now inform the representatives of the deceased’s family of this review and the vulnerability of DFT.”
The report concludes:
“We can all appreciate how easy it would have been for November 1 to have nudged the motorcycle on the approach to the bend.  I am not surprised the family of the deceased feel unhappy with some aspects of this investigation.”
Notwithstanding the view expressed by Mr Cox the family were not informed of the existence of his report nor its content until 2015.
31.	As a result of concerns raised by the claimant and her family on 2 April 2014 the claimant and her sons met with DCI Paula Light, now Superintendent Light, of the Directorate of Professional Standards.  The purpose of the meeting was to listen to their concerns.  It was agreed that a report would be prepared reviewing the paperwork in the light of their concerns and to see what, if any, options were open to the family in respect of this matter.  In the report Superintendent Light identifies the many witness statements she has seen and the areas of concern raised by the claimant at the meeting.  These were noted to include:
“…4. PC McCarthy failed to locate the witness who said that N1 had contacted the motorcycle.
5. The two statements from the driver and the operator were exactly the same.
6. The officers could not have seen the crash if they were 100m back as per their statements. 
7. PC Lamb – examination of N1, the [motorcycle] and findings.
8. The measurement of the tyre marks against N1.
9. Did N1 drive along side Mr Power and was there contact.
10. Impact of review of Mr Turner’s work OP BERAYSIM…”
32.	Superintendent Light reviews the evidence given by PC Lamb of his examination of the police vehicle, the motorcycle and his findings.  She notes the three areas of damage on the police vehicle set out in paragraph 21 above, the evidence given by PC Lamb as to these marks and his conclusion that they have not been caused by the motorcycle.  She concludes:
“The only way to prove or disprove the marks came from the [motorcycle] would have been to have performed forensic tests, but this was not completed.  I am unable whether this was a matter of policy at the time.”
33.	The evidence relating to the tyre marks on the road in respect of the police vehicle was reviewed.  Superintendent Light stated that she shared concerns that the test of the police vehicle was not conducted at the speed in which the car may have been travelling, i.e. 60 to 70 mph, on a left hand curve.  
34.	It was Superintendent Light who identified the review by Terrence Cox in March 2004.  It was conducted by the Directorate of Professional Standards to perform a historic review of expert evidence provided and used by prosecutions in a number of cases as part of a joint operation between Forensic Science Services, CPS and the police.  She concludes that the operation was to review David Turner’s calculations which were found to be correct.  In April 2005 Mr Cox’s findings were reviewed by Detective Superintendent Day and the CPS.  It was decided that the report and its findings were not to be disclosed to the family as there was no reason to believe that Mr Turner’s involvement led to a miscarriage of justice.  

Observations of the first interested party
35.	The essence of the observations relate to the absence of forensic evidence and what could now be achieved at this remove of time.  As both vehicles have disappeared it will not be open to a court to order any testing relating to either.  The whereabouts of Miss McDine are not known.  It was confirmed that PC Collier and Heatley would be available to give evidence at a subsequent inquest.  It was accepted that the cumulative force of the points raised on behalf of the claimant do raise an issue as to whether a new inquest should be ordered.  
36.	The first interested party accepted that the application could be dealt with pursuant to the provisions of the 1998 Act, it did not require consideration of Article 2 ECHR.

Conclusion
37.	The claimant did not have the benefit of legal representation at the inquest into the death of her husband.  Her request for disclosure of statements in advance of the inquest had been refused.  It was clear from her questioning of PC Lamb that the case put forward on behalf of the deceased was that he was entering the left bend from College Road but was unable to lean into the bend to safely navigate it because of the presence of the police vehicle on his nearside, at some point there was contact between the two vehicles.  PC Collier and Heatley deny this version of events.  The evidence of the driver of the police vehicle and his passenger was critical.  The fact that the two police officers had made, in effect, identical statements was a matter upon which each could and should have been questioned so as to test the credibility and veracity of each account, in particular as to speed, distance and sequencing.  One independent witness provided two statements which, on their face, could be taken as supporting the assertion of speed and contact between the two vehicles.  Her statements were read, no opportunity was afforded to the unrepresented claimant to adjourn the proceedings to permit Miss McDine to attend.
38.	In my judgment, upon these two grounds alone, there were irregularities in the proceedings, the result of which was to deprive the claimant of an informed opportunity to question each police officer as to his account of the pursuit and the collision and to elicit in oral form the evidence of Miss McDine.  
39.	The subsequent reports of Mr Cox and Dr Searle cast doubts upon the findings of PC McCarthy, PC Lamb and Mr David Turner as to the speed and direction of the police vehicle and whether there was contact between the police vehicle and the motorcycle.  The opinions of Mr Cox and Dr Searle are relevant to the fundamental issue of how the fatal accident occurred.  Both reports, and that of Superintendent Light, comment upon the adequacy of the original police investigation.  The three reports are all relevant new evidence which was not available at the time of the original inquest.  It is to the credit of the claimant, who has pursued her concerns with conspicuous tenacity, that Mr Cox’s report was finally disclosed and a meeting was held with Superintendent Light.  
40.	The reports also identify the inadequacy of the forensic testing carried out prior to the original inquest which relates to Ground Two, namely the insufficiency of inquiry.  It has not been suggested that these are not valid concerns, the point that is made is that neither vehicle is available for further forensic testing.  That may be, but it does not answer the point that at the original inquiry there was an insufficiency of inquiry by reason of the inadequate forensic testing.
41.	The question to be answered is whether it is in the interests of justice for a fresh inquest to be ordered?  By reason of my findings as to the irregularity in the proceedings, the insufficiency of inquiry and the emergence of relevant new evidence, the question has to be answered in the affirmative.  In reaching this conclusion I take account of the considerable lapse of time which has occurred since the original inquest which brings with it the uncertainty of the availability of relevant witnesses (paragraph 34 above) and what effect the years will have upon their recollection of events.  Notwithstanding these matters the cumulative effect of the significant deficiencies in the original process provide a powerful weight to set against the factors resulting from the lapse of time.  The result being a balance decisively falling in favour of a new inquest.
42.	A jury at a new inquest will be better informed to enable it to arrive at a verdict by reason of properly informed questioning of relevant witnesses, objective and independent assessment of the forensic testing and the original police investigation.  It will be open to a new jury to return a narrative verdict which, it is to be hoped, would bring a measure of closure for the claimant, who for twenty years has fought tenaciously on behalf of her husband.  
43.	Accordingly, in my view, the original inquest touching upon the death of Mr Onese Power must be quashed and a fresh inquest held into his death.  

Lord Justice Lindblom: 
44.	I agree.