How the Coroner Dealt with the Case -Part 1

The next series of posts will centre around my dealings with the Senior  Coroner Mr John Leckey. He has since  retired from his post.

So that you can more easily follow my dealings with the Coroner, I will  briefly repeat some details in the lead up to the last case in the Coroner’s Court on 19th May 2009. This was before the Kennedy Investigation  (Post dated 20th August 2018) and before the Police Ombudsman’s apology (Post dated 13th August 2018) but just after my case in the High Court had been abandoned.



 I had unsuccessfully worked my way through the Justice System for 6 years to try to remove the stain on my brother’s memory, to obtain justice against Carson and to get rightful compensation for his widow.  During that period I had been told by several doubters (including one anonymous caller who offered to take severe action against Carson) that I would not be able to challenge “them” but I didn’t want to believe that they were right. I always replied that all it took was one person within the system to stand up and say that there was merit in my case and  the whole matter would be re-investigated.

If Sgt McBride’s Report was wrong by his own admission, then  surely his superior officer Inspector Ian White would realise that he could not present his unamended Report as evidence without leaving himself open to perjury. However, he failed to insist on corrections or recommend re-investigation and he refused to act on sensible suggestions by the Ombudsman. He also chose not to reconstruct the collision at the scene as suggested by the Coroner. He was an immovable object.

When Chief Constable Orde was personally made aware that the Report was wrong, he did nothing but refer me back the Ombudsman’s Report. When the Police were given fairly conclusive evidence that the first emergency call was made at 1449, they simply corruptly amended the official time of the collision from 1450 to 1443.

The Ombudsman had accepted the errors but wrote to the Coroner that the Police Report was “factually based”.  Even after Mr Kane, as an experienced Police Investigator, was called in, and in almost all respects supported me and my findings, he was not allowed to publish his conclusions. His findings were not even taken into account, even though he had been called in to bring a level of expertise to the investigation by the inexperienced Mr Meehan.

The Forensic Officer Coll stated that his Report was less than he would have wanted and agreed to look at it again after consulting the Coroner only to reinforce his original conclusions in his second Report.

The DPP had put the case on the long finger pending the outcome of the Coroner’s Court. Previously the DPP had rejected my submission after failing to read the evidence presented by me. The case still waits for a decision.

Finally, my own civilian accident investigator had done a volte face at the last minute and changed his Report to agree with the Forensic Officer. He was a key witness in my case in the High Court and he reversed his conclusions after apparently receiving the Second Report by the Forensic Officer.

In my view this was a fallacious reason because there was nothing new in Coll’s second Report that could possibly change his conclusion. All it did was reinforce the errors in his first Report (See Post dated 11th June 2018.) Secondly, as an independent expert witness he is expected to arrive at his own conclusions without interference through collusion with Coll

  He was certainly also under instruction from Coroner Leckey to harmonise his findings with that of the Forensic officer and of course  there is every possibility that he could  also have been under similar pressure from some other interested party. It is a criminal offence for anyone to put pressure on a witness to change his evidence other than by pointing out new factual evidence not previously known,  but such behaviour is apparently accepted in our Justice System.  People have ended up in jail for less.

You might ask Cui Bono, or, if  your Latin is as rusty as mine, who benefits from his gigantic leap in the opposite direction. I will explore those questions in a later post. The possible list includes Carson, Police witnesses, Forensics, Insurance Companies, Coroner, Police Ombudsman, my Legal team and McLoughlin (the civilian investigator). All had possible reasons to make the Civil case go away.

As a direct result of McLoughlin withdrawing his evidence just a matter of weeks before the case was to go to Court, DAS, the Legal Insurance Company whose policy Raymond held, withdrew their support and my Legal team who was being financed by DAS had no choice but to withdraw from the case.


I may explore all of that in a later post.



I had worked my way through the System and instead of achieving a resolution, I had hit an unbreachable brick wall.  It seemed to me that by some mechanism, not understood by me, a circle of mutual support had been created amongst the various elements of the Justice System to ensure that one or other element could not be challenged. Each challenge was rebuffed by reference to another member in the circle. Each element proclaimed itself to be independent of the other, but instead each acted as a link in a chain which was interdependent on the others. I characterised it as a type of masonic, where I am told that there is an unspoken understanding of expected mutual support if required, solely on the grounds of a common membership. If I was right then none of the organisations were independent and therefore none could be considered to be fit for purpose.  Perhaps because this is a small parochial society where the participants work with each other on cases on an almost daily basis, this loss of independent action is the result. Justice cannot be achieved in such an arrangement unless each link fiercely defends its independence from the others.  If this mutual support has, to any degree, become institutionalised then no one should rely on those organisations to seek justice given that their overriding and primary need is to protect each other. They are not to be trusted.


Up to the point where my private Accident Investigator McLoughlin changed his conclusion, my legal team was convinced that we had a case to present before the Court. Thereafter, they decided that we had no case.

I had often been reminded of the hoary old story of the proud mother watching her son marching in a platoon of soldiers and exclaiming “Look, my son is the only one in step!”

It would be easy to assume that the mother was delusional and and one might excuse her blind but misplaced faith in her son’s prowess. It would be extremely difficult to prove that she might be right in what she said. But she could be. Why? Maybe the son had alienated the other soldiers somehow or perhaps he just wasn’t a team player. What really happened was that the rest of the platoon had decided to change step on a given signal but without telling the son of their plan.  The result was that the son was in step and the rest of the platoon was not. His mother was right.

It took one honourable soldier to come forward and tell what he knew. I waited but no one inside the Justice platoon stepped forward. Their first loyalty was to the other members of their platoon. Mr Kane wasn’t a full member and perhaps didn’t have the same loyalty but he was leaned on and prevented from telling what he knew.

I knew I had let my family down because all the stress over the past 6 years was for nothing in spite of me reassuring them that it would come right in the end. I wasn’t misleading them. It was what I believed. I had a faith that the system would work and eventually discover the truth and thus justice. I was wrong.

Up to now I had acted under the terms of Letters of Administration which obliged me to recover compensation for my brother’s death if it was justified. I could no longer act under the authority of that document since there was no chance of compensation being paid.

Up until the time that McLoughlin changed his Report to fall in line with the Forensic Report, my legal expenses were mainly paid for by a Legal Insurance Policy with DAS  which had been taken out by my brother alongside his vehicle Insurance. That policy was promptly closed. 

I called the family together and told them what had happened. I said that the Coroner’s Inquest would now be held, and, whereas it had been my intention to represent the family in that Court, things had changed and they had to consider now if they would prefer to be represented by a legally qualified person instead. Had the Civil proceedings been successful, it would have been easy to suggest that my legal team could have continued their representation in the Coroner’s Court.  That option was no longer available.  I told them that I would be willing to fully brief any person they chose. I wasn’t sure that Legal Aid was available for a Coroner’s Court but I would enquire. (The Coroner later confirmed that it was.) I asked them to take time to consider their options and to arrive at a joint decision. I did not try to influence their decision in any way. The decision was made over the next few days and they returned and asked me to represent their interests in the Coroner’s Court. I could not refuse and prepared myself for one final push.

The first thing to do was to brief myself on the workings of the Coroner’s Court. I contacted the Coroner’s Office for advice and they suggested I read a copy of what they called “the little yellow book” which in fact was a book called Coroners’ Law and Practice in Northern Ireland written and published in 1998 by the very Senior Coroner who would be dealing with my case. His fellow author was a senior law Officer at Queens University.  It was referred reverentially by members of the Coroner’s staff as the Bible of the Coroners Service. I visited the reference Library at the Linenhall Library and worked my way through its contents. I read it as a layman without any legal background but I think that I understood enough of it to represent the family in the upcoming hearing. No doubt, the Coroner would correct me if I strayed from the rules.

The Coroner is an independent judicial officer who is responsible for matters relating to deaths that may require a further investigation so as to establish the cause of death. He inquires into deaths reported to him that appear to be as a result of accident or negligence or in circumstances that require investigation or further investigation. 

In 1980 he no longer gave his conclusion as a narrow “verdict” but as “findings” which greatly widened his scope in being able to comment more fully on the death being investigated. He has a special responsibility in connection with any evidence which might suggest that the death could have been the result of dangerous driving. He also had responsibility where he would draw attention to the existence of circumstances which, if not remedied, might lead to further death. It occurred to me that the reversal of unidirectional tyres fell into that category. Was it not a Coroner many years previously who drew attention to the danger of mixing cross ply and radial tyres on the same chassis and so saved countless lives? The recent illegal sport of drifting on public roads could also be a worrying concern worthy of comment in his findings.

In this case he had a special responsibility imposed on him by the DPP who were awaiting his “findings” before they made a decision how to proceed with the case I had presented to them.

The Coroner’s Court is unlike a typical Criminal or Civilian Court in as much that it is inquisitorial process as opposed to the more traditional adversarial nature one might be familiar with.

I quote: “There are no parties, no indictment, no prosecution, no defence and no trial and it is the Coroner who decides which witnesses will testify and what other evidence will be adduced. The formal rules of evidence do not apply and the Coroner generally assumes a more dominant role in the proceedings.”

Elsewhere it states that “without prejudice to any enactment with regard to the examination of witnesses at the inquest, any person who, in the opinion of the Coroner is a properly interested person shall be entitled to examine any witness at the inquest either in person or through a solicitor, provided that the Coroner shall disallow any question which in his opinion is not relevant or is otherwise not a proper person.” 

The importance of this right will become clear later.

“The sympathies of Coroners, as far as justice allows, should lean towards the people other than towards official or otherwise entrusted bodies.”

The relevance of this statement of purpose might well be understood later.

The book also states:  “It is the duty of the Coroner as the Public official responsible for the conduct of inquests to ensure that the relevant facts are fully, fairly and fearlessly investigated. He must ensure that the relevant facts are exposed to public scrutiny. He fails in his duty if his investigation is superficial, slipshod or perfunctory.”

The importance of this statement will also become clear later.

I had been in contact with the Coroner during the whole investigation process and provided him not only with my written statement but with all the evidence which supported it. I had at various times sent him Reports, additional evidence, photographs, maps etc as they became available. Undoubtedly he was receiving similar material from the other parties who would have kept him informed and updated.  His file must have been at least as thick as mine which was over 800 pages. He had been approached previously by the Forensic Officer and had been told by him to write a second Report. He had also been involved when he secured an agreement with the Police to have the collision re-staged at the scene.  He would also have been aware that subsequently no such enactment happened. I had kept him informed about my investigation into the change of time of the accident and my evidence for querying   it. So far as I knew he had all the information which I had and probably more.

On 22nd January 2009, I wrote to him and advised him that the case to be held in the High Court would not now go ahead and that this was because our accident investigator Mr McLaughlin had changed his conclusions to be more  in line with the findings of the Forensic officer. I also advised him that my legal team were now off record and my duties under the Letters of Administration were at an end. I told him that  Raymond’s family had asked me to continue to represent them but I would only do so if I would  be allowed to question witnesses and that he should consider the question of death by dangerous driving in his findings or to recommend a new investigation. I asked for his advice on whether it would be more appropriate for the family to be legally represented in which case Legal Aid would be needed. He wrote back to say that he couldn’t advise the family but should they choose the latter, then Legal Aid was available in certain circumstances.

I passed this on to the family and they signed a document to say that they wished me to represent their interests.

On 4th March I wrote to the Coroner again and asked him to consider calling Police Constable Cochrane who had examined the vehicles post accident. I asked for  Station Sergeant Gavin Jones from the Central Control to attend. I also asked that Mr Cane and Mr Meehan from the Ombudsman’s Office be called. They had already agreed that their evidence was best put to the Coroner.

In the letter I explained to him that as far as I was concerned there was compelling evidence that this was a clear case of death by dangerous driving but that was not reflected in the evidence which had been assembled by the Police or Forensics. I went on to say that there were several videos which the Court might wish to see. I informed him that I had produced a large-scale map of the collision site together with scaled  car models which might assist the Court in its deliberations.

He wrote back saying that he was prepared to call Constable Cochrane, but not Station Sergeant Jones given that his evidence had been investigated by the Ombudsman. So far as I was aware he knew it had not.

He would not agree to call Mr Meehan of PONI as “your complaint has been dealt with.” It seemed to me that he ignored the fact that Mr   Meehan held evidence which had not been seen by any of the rightful recipients and had stated that he would not release it except to the Coroner.

He asked me to provide him with a copy of the report of Mr Cane to allow him to consider its relevance.

He told me that it was my job to refer the circumstances to the DPP and ask that they reconsider my allegation of dangerous driving. I had previously told him that they were in fact waiting for his inquest result. 

On 17th March, I wrote back :

“My reason for calling  Station Sergeant Jones  is  because his evidence was not investigated by the Ombudsman because of lack of resources, and if he continues to insist that the first emergency call was made to his Control at 1443 in the face of irrefutable evidence, then he should also explain why it took his Controller at least 7 minutes to alert the Police or ambulance. This could have implications for the survivability of my brother.

Mr Kane reviewed this case for the Ombudsman and I received  a verbal Report from him in the presence of Mr Meehan, but he was prevented from making a written Report by the Ombudsman’s Legal team even though he was willing to do so. I consider his findings at least as relevant as Mr Meehan’s which are contradictory, but I must be guided by you. I enclose a copy of Mr Cane’s Report as stated to me.

I have included a copy of a letter which I received from the DDP dated 18th March 2008 in which they state that they will await the conclusion of any proceedings in the Coroner’s Court before they consider my submission and evidence for a possible charge of causing death by dangerous driving against Mr Carson.

I am happy to allow Mr Coll to view the map and scaled models at any time before the case in your Court, but I believe them to be inch perfect and would help to explain many points to the Court, but I imagine that if he rejects them then they cannot be used.”

He wrote back saying that he would make arrangements for Mr Coll to view the map and scale models. He also said that “Mr Cane was tasked to carry out a review of a general nature and I cannot see how he would be able to give relevant evidence in relation to the accident in which your brother tragically lost his life.”

A few days later, I took the map and models to the Coroner’s Office and gave them to Mr Coll and he took them away for inspection. I was a little disconcerted to find that he had a folder containing the second Report from my erstwhile accident investigator Mr McLoughlin together with a letter which I had sent to my solicitor detailing my meeting with Mr Kane. I wondered to what extent information, including a letter between me and my solicitor, should be redistributed. He asked me what the Ombudsman had said about the expert witnesses in the case. I decided to tell him but the Coroner’s representative stopped me and said there should be no discussion outside of the exhibit inspection.  The staff member informed me that the case would be held on 19th May 2009 and he would provide me with a list of the witnesses that would be called.

 The list included Constable Cochrane the police Vehicle examiner and Sergeant McBride, but it did not include the Station Sergeant in the Control Centre.

Witness 3, the female teacher who was waiting at the stop line at the junction when the Subaru drove past at 80 to 90 MPH, who had previously been on the list, was removed from the list. 

Mr Hicks the civilian drifting instructor wasn’t on the list either. I might have liked him there to explain drifting techniques and the danger of reversing tyres but he lived in England and so I didn’t press the point. Perhaps his Report was sufficient.

Witness 4 the civilian witness who called the Police and who would say that the Subaru passed him at 80 or 90 mph just half a mile from the accident was not on the list.

 Mr Kane and Mr Meehan from the Ombudsman weren’t included.

The Coroner’s inquest was to be held with several important witnesses absent, but at the end of the day it was his decision and his choice. It would make my job even harder but frankly I was tired of fighting and beating my head against a brick wall and so I simply wrote and asked for the inclusion of Witness 4 and left it at that. He was belatedly included in the list of witnesses to be called.

I have no experience of representing anyone in Court, so it was a case of detailed preparation before the case in order to improve performance on the day.

I knew the points which were relevant to prove my case and since they were contained throughout 800 pages of my file and could not be instantly recoverable during the case, I decided I needed to get organised.

I took the witnesses in turn and I wrote down all the questions I would ask them about evidence which was either absent from their statements or was wrong in their Reports.   Each question would be supported by photographs or documents from my file. For ready access in the event that the reply from the witness differed from the evidence held by me, I would extract the evidence from the file. I made three copies of each piece of information and included the material in the witness envelope. The idea was that I could instantly refer to any relevant piece of contrary evidence and at the same time give a copy to the witness and one to the Coroner.

I assembled all the relevant photographs and made up two folders, one for questions essentially to the Police and one for questions to the Forensic Officer. Again I made three copies, one for me, one for the witness and one for the Coroner.

Each witness had their own self-contained set of questions and evidence for use by me. In this way I hoped to avoid stumbling through the questions and being unable to find anything. It was laborious and expensive and time-consuming but it had to be done.

I was as prepared as I could be and might cope if given a degree of latitude by an understanding Coroner. I felt a little more confident of what I was trying to do.

Someone had once told me that if I felt at all intimidated by the surroundings or the magisterial presence of the judge I should conjure up a picture of him wearing a pair of suspenders and stockings and high heels hidden only by the bench. The fear would dissipate. I didn’t need to.  During the process, the principal of my Solicitors firm called with me and kindly offered any assistance I might need in preparing for the case. He also assured me that the Coroner would give me a sympathetic ear and would help me through the process. He would understand that I wasn’t a trained lawyer and would make allowances. It was reassuring and encouraging and I began to relax.  I had dealt with the Senior Coroner before and he had shown general interest in the case and had tried to resolve differences in the evidence by requesting a staging at the scene and requiring the Forensic officer to write a second Report. On the other hand, at a previous hearing, he had blamed me for the non-attendance of my accident investigator at the Court even though I explained that he had to attend the High Court at the same time. I didn’t dare tell him that all witnesses were his and not mine. Had he looked round the court room he might have realised that several witnesses were not in attendance because none of us had received a summons to appear, but had turned up solely on receipt of the initial letter from his office that a date had been set for the hearing. I had decided to accept the rebuke and not blame his staff. Why would I start off in his bad books.

The stage was set.



The next post will detail what went on in the Coroner’s Court.

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