The claim is brought under section 13(1)(b) of the Coroners Act 1988, as amended, (“the 1988 Act”), with the fiat of the Attorney General dated 15 May 2024, for an order that:
(i) the determination and findings of the investigation and inquest held into the death of Leonardo Pronesti be quashed and
(ii) the Claimant do conduct a fresh investigation and hold a fresh inquest into the death. [2]
The Deceased had a history of mental health difficulties and self-harm with suicidal ideation… [6]
On 21 December 2017, a package was left at the Community Mental Health Unit…One of the nurses at the unit examined the package… he was later to state, “seemed likely to be indicators of suicidal ideation/preparation, although no suicide note.” [8]
The police attended at the Deceased’s home on 25 December 2017 in order to conduct a welfare check on the Deceased who was found hanging in the hallway with cuts to his wrists. He was pronounced dead at the scene. [12]
On 3 January 2018, an Inquest was opened… and over the following 6 months evidence was gathered for the purposes of the inquest. At some point during this period, the package of documents, which had been left at the mental health unit on 21 December 2017, was delivered to the coroner’s officers’ office… [15]
the file of evidence subsequently provided to the Assistant Coroner, who heard the inquest,… it did not contain the package containing the documents. [16]
The Assistant Coroner heard the inquest on the 29 August 2018… It is apparent from the transcript of the inquest that there were some references to letters and envelopes, and some handwritten notes from the Deceased were placed before him. However, in his subsequent witness statement, the Assistant Coroner states that he did not appreciate that the package of documents existed and he made no enquiry concerning them. [17]
the Assistant Coroner found and recorded in the Record of Inquest that, “On 25 December 2017, Leonardo Pronesti was found hanging as a result of his own actions at his home address. He died as a result of asphyxiation caused by hanging but there was insufficient evidence to indicate that he intended to take his own life”. [18]
Subsequently, on 13 December 2018… the contents of the package of documents were located in a drawer in the coroner’s officers’ office… When the package was opened it was found to contain hundreds of pages of the Deceased’s notes, messages, letters, and drawings, which included many references to suicidal ideation. [19]
On 21 February 2019, the documents were provided to the Assistant Coroner, who considered them. On 5 March 2019, he provided a written note to the effect that the documents would have been relevant to his findings at the inquest and, had he taken account of them, he would probably have recorded a conclusion of suicide. [20]
we will grant the application, quash the determination of the Assistant Coroner and findings of the investigation and inquest held into the death of the Deceased, and order the Claimant to conduct a fresh investigation and hold a fresh inquest into the death of the Deceased [39]
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