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You are here: BAILII >> Databases >> England and Wales High Court (Administrative Court) Decisions >> Gamesys Operations Ltd, R (On the Application Of) v HM Senior Coroner for London Inner South [2025] EWHC 659 (Admin) (27 February 2025) URL: http://www.bailii.org/ew/cases/EWHC/Admin/2025/659.html Cite as: [2025] EWHC 659 (Admin)

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IN THE HIGH COURT OF JUSTICE
KING'S BENCH DIVISION
ADMINISTRATIVE COURT

		The Royal Courts of Justice Strand London WC2A 2LL
		27 February 2025

1. MRS JUSTICE LANG: The claimant renews its application for permission to apply for judicial review of the decision of the defendant ("the Coroner") to appoint Professor Dame Clare Gerada, who I shall refer to as "Professor Gerada", to act as an expert witness on gambling disorder at the inquest touching on the death of Mr Lee Adams.
2. Sadly, Mr Adams died on 24 July 2020 from cardiac arrythmia and an overdose of medication.
3. The interested parties, who I shall refer to as "the family", are the sister and cousin of Mr Adams and I extend my condolences to them on their loss.
4. Permission to apply for judicial review was refused on the papers by Simon Tinkler, sitting as a Deputy High Court Judge, on 28 November 2024.
5. The claimant operates online gambling sites, including some sites used by Mr Adams.

Following the first pre-inquest review hearing on 20 May 2022, the Coroner found that expert evidence was required on the question of whether gambling, or an undiagnosed gambling disorder, had contributed to the death of Mr Adams.

6. At the second pre-inquest review on 27 June 2023, the Coroner directed that the claimant, who appeared on that occasion by its managing director, should be an interested party at the inquest. On that occasion, Leigh Day, solicitors for the family, invited the Coroner by letter and then in oral submissions to appoint Professor Gerada as an expert witness. The Coroner gave the interested parties at the inquest ten days to submit the names of any other experts.
7. On 21 September 2023, the claimant wrote to the Coroner expressing concern at the proposed appointment of Professor Gerada on the grounds that she was not impartial. It suggested Dr Frazer as an alternative expert. He is a consultant psychiatrist, who has also worked as a forensic psychiatrist and has experience in gambling disorders.
8. The selection of expert witnesses was discussed at the third pre-inquest review on 28 September 2023. The parties then made further written submissions to the Coroner. The claimant made detailed submissions, with supporting materials, in favour of Dr Frazer and opposing Professor Gerada. Leigh Day submitted that Dr Frazer lacked the specialist expertise required and that Professor Gerada was a leading expert who had the necessary independence.
9. By an email of 6 June 2024, the Coroner informed the parties that he had decided to instruct both Professor Gerada and Dr Frazer to act as expert witnesses. That email was followed, on 28 June 2024, by a more detailed email from the Coroner confirming that Professor Gerada had agreed to act as a gambling disorder expert and Dr Frazer had agreed to act as a expert consultant psychiatrist. In light of the disagreement between the parties on the draft letters of instruction, he invited comments from the parties before he finalised the letters.
10. The claimant then sent its judicial review pre-action protocol letter to the Coroner on 23 July 2024 and filed this claim on 3 August 2024. The inquest is currently due to be listed in June 2025.

Statutory framework

11. Pursuant to section 1(1) of the Coroners and Justice Act 2009 ("CJA 2009"), the Coroner has a duty to conduct an investigation as soon as practicable into the death of Mr Adams. The duty to investigate includes the duty to hold an inquest (see section 6 CJA 2009).
12. By section 5(1) CJA 2009, the purpose of the investigation is to ascertain "(a) who the deceased was; (b) how, when and where the deceased came by his or her death; (c) the particulars (if any) required … to be registered concerning the death".

Claimant's grounds of challenge

Core submission

13. The claimant's core submission is that Professor Gerada is not suitable to be an expert witness, as she is partial and not objective on the issues on which she will be instructed to give evidence.
14. The specific concerns are summarised by the claimant as follows,

1. Professor Gerada is a leading antigambling campaigner expressing staunch opposition to the gambling industry, including that it should "realign its moral compass", be subject to "much more responsibility" and "made to pay for gambling disorder patients".

2. Professor Gerada holds fixed and strong negative views on gambling itself.

3. In October 2022, Professor Gerada publicly advocated for coroners to record gambling as a causative factor in suicide inquests; that was the verdict at the previous inquest at which Professor Gerada gave evidence and that is what Leigh Day has urged the Coroner to do in this case.

4. Professor Gerada leads the NHS primary care gambling service. This service is funded by "Gamble Aware", which is implacably opposed to the claimant.

5. Professor Gerada recently gave written evidence to a Select Committee Inquiry. Her evidence was contrary to the interests of, and position adopted by, the claimant.

6. Leigh Day recommended Professor Gerada to act as an expert witness on gambling disorders at another inquest.

7. Professor Gerada's son is a solicitor at Leigh Day.

8. Until about 2014, Mr Adams and the family attended the GP surgery at which Professor Gerada was practising. She was not their named GP and she has no recollection of seeing Mr Adams or members of his family. But it is possible she saw them in consultation at some point and Mr Adams' name may be familiar to her.

Ground 1

15. Under ground 1, the claimant submits that the Coroner, in making his decision, failed to take into account mandatory relevant considerations material to the exercise of his discretion, or did not accord them sufficient weight. The mandatory relevant considerations are the concerns about independence and impartiality, which the claimant brought to the attention of the Coroner in its oral and written submissions.

Ground 2

16. Under ground 2, the claimant submits that Professor Gerada is so obviously partisan that her appointment as the court's expert infects the Coroner with bias or at least gives rise to a reasonable apprehension of bias.

Ground 3

17. Under ground 3, the claimant submits that the coroner's decision was irrational because no reasonable coroner would have appointed Professor Gerada as an expert witness.

Ground 4

18. Under ground 4, the claimant submits that the coroner did not provide any or any adequate reasons for his decision.

Family's response to the core submission

19. In response to the claimant's concerns about Professor Gerada, the family submits that Professor Gerada is a general practitioner and former President of the Royal College of GPs. She is a qualified psychiatrist and a Fellow of the Royal College of Psychiatrists, though not registered to practise as a psychiatrist. She is a national leader in the fields of addiction and substance abuse, with particular knowledge of gambling harm and its impact. In 2000, she was made an MBE for services to medicine and substance misuse and in 2020 she was made a DBE for services to medicine and mental illness. She is not an anti-gambling campaigner; she is a highly-respected health professional with expertise in the mental health condition of gambling addiction/disorder.
20. The fact that Professor Gerada leads the NHS Primary Care Gambling Service is an indication of her expertise. The service receives funding from Gamble Aware, which is a reputable independent charity that acts as the strategic commissioner of gambling harm and treatment. Gamble Aware is funded by voluntary donations from the gambling industry as the industry also states that it wishes to reduce gambling harm.
21. The family submits that, as an expert, Professor Gerada will owe a duty of independence to the court, a duty which she has applied on numerous previous occasions when acting as an expert witness in legal proceedings, including in coronial proceedings concerning gambling related suicide. She, therefore, appears well placed to assist the Coroner on issues which he is investigating.
22. The family submits that the connection between the family and Professor Gerada's GP practice was disclosed to the Coroner before he made his decision to appoint Professor Gerada. I also observe that Professor Gerada will not be giving evidence as a treating physician. In my view, the connection through the GP's practice is insufficient to give rise to any arguable conflict of interest.
23. Leigh Day submits that the criticisms of its firm and any connection with Professor Gerada are unjustified. Professor Gerada's son works as a solicitor at Leigh Day, but he works in a different department in another area of work. In my view, this connection is insufficient to give rise to any arguable conflict of interest.
24. The family submits that there is nothing improper in the fact that Professor Gerada was proposed by Leigh Day as an expert witness in a previous inquest. She was identified because she has prior expert knowledge of gambling and gambling disorder. Prior contact between a firm of solicitors and an expert does not call into question an expert's independence. I agree with this submission by the family. I observe that it is commonplace in fields of work, such as clinical negligence, for solicitors to instruct the same experts for similar cases.
25. The claimant has suggested that Leigh Day are "anti-gambling campaigners". Leigh Day submits that this is incorrect and unjustified. They are a highly reputable firm of solicitors acting to represent their clients in accordance with their professional and regulatory duties.

The Coroner's role

26. An inquest is an inquisitorial rather than an adversarial proceeding. It is the duty of the coroner to ensure that the relevant facts are fully investigated. In conducting that investigation, the Coroner is afforded considerable discretion as to the scope and breadth of the enquiries that he chooses to conduct (see the authorities cited at paragraph 33(a) and (b) of the family's summary grounds of resistance).
27. The Coroner's broad discretion in the conduct of his investigation applies to decisions on which witnesses to call. In R (Mack) v HM Coroner for Birmingham [2011] EWCA Civ 712; [2011] Inquest LR 17 at paragraphs 8 and 9, Toulson LJ explained:

"…  the coroner [has] a wide discretion – or perhaps more appropriately a wide area of judgment – whom it is expedient to call".

28. I also refer to R (McGuire) v Assistant Coroner for West Yorkshire [2018] EWCA Civ 6; [2018] inquest LR 83 at paragraph 3, per Lord Burnett of Maldon CJ and Nguyen v HM Assistant Coroner for Inner West London [2021] EWHC 354 (Admin) at paragraph 75.
29. This broad discretion on witnesses applies also to coronial decisions on expert witnesses: see R (Lepage) v HM Assistant Deputy Coroner for Inner South London [2012] EWHC 1485 (Admin), paragraphs 43 and 49; R (Takoushis) v Inner North London Coroner [2006] 1WLR 461 at paragraphs 60 to 61; and R(Warren) v HM Assistant Coroner for Northamptonshire [2008] EWHC 966 (Admin) at paragraph 41.
30. Where a challenge is brought to a coroner's decision on witnesses, the question for this court is whether the decision was Wednesbury unreasonable (see McGuire at paragraph 3; Nguyen at paragraph 75; Lepage at paragraphs 43 and 57). As Lord Burnett observed in Mack at paragraph 9,

"The court will only intervene [in a decision on witnesses] if satisfied that the decision made was one which was not properly open to [the coroner] on Wednesbury principles".

The threshold for a finding on Wednesbury unreasonableness is very high.

31. In approaching a challenge to this Court to a coroner's broad discretion, the High Court has previously recognised that it will be

"unwilling … to fetter the discretion of a coroner by being at all prescriptive about the procedures he should adopt in order to achieve a full, fair and thorough hearing ([R v Coroner for Lincolnshire ex parte Hay [1999] 163 JP 666, at paragraph 46, approved in Lepage at paragraph 48])".

32. This Court has also stated that, "This court cannot dictate what witnesses the coroner calls": R (Lin) v Secretary of State for Transport [2006] EWHC 2575 (Admin), at paragraph 56, per Moses LJ).

Rationality and relevant considerations

33. In my judgment, the claimant has no prospect of success in a rationality challenge to the Coroner's decision to invite Professor Gerada to give expert evidence on the question whether or not gambling was a causative factor in the death of Mr Adams. The Coroner conducted an exhaustive process in deciding which expert witnesses to call. He had extensive written oral submissions from the claimant on the one hand, and the family on the other, each presenting a different point of view and recommending a different expert.
34. The evidence of Professor Gerada's qualifications and expertise in this area was convincingly strong. She also has experience of appearing as an expert witness and will be aware of the duties that expert witnesses owe to the court. She has relevant experience that Dr Frazer does not have. In what I consider to be a scrupulously fair and balanced decision, the Coroner decided to invite both Professor Gerada and Dr Frazer to give expert evidence. Since their areas of expertise and professional backgrounds are different, they are likely to bring different perspectives to the evidence, thus enhancing the quality of the investigative process. Both the claimant and the family can feel reassured by the fact that their nominated expert has been invited to give evidence by the Coroner.
35. In my view, it is not credible that the Coroner failed to take into account the claimant's concerns about the independence and impartiality of Professor Gerada, when the claimant has repeatedly raised these issues with the Coroner in its extensive submissions.
36. The Coroner will also have had regard to the family's response, disagreeing with the claimant's concerns. The weight that the Coroner accorded to these concerns was a matter for the Coroner's discretionary judgment. Neither the claimant nor this Court can dictate to the Coroner which witnesses he can or cannot call.
37. In my view, it is important to bear in mind that the claimant is not a disinterested observer. Its aim is to protect the reputation and success of its business. However, protection of the claimant's legitimate business interests is not the purpose of this inquest.
38. On the evidence before the Court, the Coroner intends to ensure that the evidence given by Professor Gerada and others does not stray beyond the circumstances of Mr Adams' death.
39. In his directions following the first pre-inquest review in May 2022, the Coroner stated:

"I am conscious and cautious of the inquest appearing to become involved in the political aspects of safeguarding potential problem gamblers, because, as the parties are aware, that is not an arena I can enter".

40. That has remained the Coroner's position throughout and, as I understand it, Professor Gerada will not be invited to opine on the wider issues concerning the safeguarding of problem gamblers. If she seeks to do so, or is questioned about such matters, then the Coroner will no doubt intervene to prevent this. The letter of instruction to Professor Gerada will be an important means of restricting her evidence to the relevant issues as determined by the Coroner. Giving the claimant and the family the opportunity to try and agree a letter of instruction to Professor Gerada and Dr Frazer is another example of the Coroner's careful and fair case management.

Bias and fairness

41. I accept the family's submissions that, in considering the lawfulness of the approach of the Coroner, the essential touchstone is one of the fairness of the proceedings. In R v HM Coroner for North Humberside, ex parte Jamieson [1995] 1 QB 1 at paragraph 26, Lord Bingham referred to the duty to ensure that the "relevant facts are fully, fairly and fearlessly investigated". As expressed by Brooke LJ in the Divisional Court in Hay,

"We are unwilling for our part to fetter the discretion of a coroner by being at all prescriptive about the procedures he should adopt in order to achieve a full, fair and thorough hearing"

and

"subject to the need to obey the requirements of the Act and the rules, it is for each coroner to decide how best he should perform his onerous duties in a way that is fair as possible to everyone concerned …"

42. I agree that the independence and impartiality of an expert may be relevant in considering fairness, if it arises on the facts of the case. If and insofar as the Coroner suggests otherwise in his responses to this claim, I disagree.
43. In civil litigation, the independence of an expert is not assessed against the test for apparent bias and an expert's interest in proceedings is not an automatic bar. In Fields v Leeds City Council [2011] 2 CPLR 129, the defendant council called one of its own employees as an expert, but the fact of employment did not mean that the employee was incapable of being an independent expert. In so finding, Lord Woolf MR held that, before a person would give evidence as an expert, the court had to be satisfied on two counts: (1) that the person had the relevant expertise in an area in issue; and (2) that the person was fully aware of the primacy of an expert's duty to the court.
44. The claimant in this claim has referred to the decision in Liverpool Roman Catholic Archdiocese and Trustees Inc v Goldberg (No.3) [2001] 1 WLR at paragraphs 6 to 14, which imports, in relation to experts in civil litigation, a test of apparent bias. However, that approach was disapproved by the Court of Appeal in R (Factortame) v Transport Secretary (No. 8) [2003] QB 381, which indicated that Fields sets out the correct position. Lord Phillips said at paragraph 70, pages 409H to 410B:

"This passage [in the Liverpool case] seems to us to be applying to an expert witness the same test of apparent bias that would be applicable to the tribunal. We do not believe that this approach is correct. It would inevitably exclude an employee from giving expert evidence on behalf of an employer. Expert evidence comes in many forms and in relation to many different types of issue. It is always desirable that an expert should have no actual or apparent interest in the outcome of the proceedings in which he gives evidence, but such disinterest is not automatically a precondition to the admissibility of his evidence. Where an expert has an interest of one kind or another in the outcome of the case, this fact should be made known to the court as soon as possible. The question of whether the proposed expert should be permitted to give evidence should then be determined in the course of case management. In considering that question the Judge will have to weigh the alternative choices open if the expert's evidence is excluded, having regard to the overriding objective of the Civil Procedure Rules".

45. Thus, even in a civil claim, an expert's interest in a topic is merely a factor to consider in the course of case management, with reference to the overriding objective and other factors such as the alternative choices available. In the context of an inquest, the assessment is to be had with reference, even more broadly, to the inquisitorial nature of the proceedings and the very broad powers of a coroner, including the need to act fairly.
46. Moreover, conflicts of interest compromising the independence of an expert will ordinarily only arise where the expert's opinion is or may be influenced by their personal interests (see the analysis in Bux v General Medical Council [2021] EWHC 762 (Admin) at paragraphs 22 to 33).
47. As I have already said, when considering the claimant's core submissions, Professor Gerada's connections with Leigh Day and the family are not even arguably sufficient to amount to a personal conflict of interest which would prevent her from acting as an expert witness. Those matters were made known to the Coroner.
48. The Coroner has rationally concluded that Professor Gerada's professional interests in addiction and gambling disorders and the views she has previously expressed do not render her unsuitable to be an expert witness on the question of whether gambling or a gambling disorder contributed to the death of Mr Adams.
49. The Coroner emphasises that this is merely the first stage in the selection of expert witnesses and their evidence has not yet, of course, been considered.
50. In the light of the scrupulously fair way in which the Coroner has conducted the proceedings so far, the allegation that his decision to invite Professor Gerada to give expert evidence gives rise to a perception of bias on his part is, in my view, unarguable and has no prospect of success. I refer, in particular, to the Coroner's careful consideration of the potential experts, with the assistance of both the claimant and the family; the Coroner's decision to ask both Dr Frazer and Professor Gerada to give expert evidence; and the Coroner's exclusion of the "political aspects of safeguarding potential problems for gamblers" from the scope of his investigation.

Prematurity

51. The Coroner emphasises in his submissions that the claim is premature, as he is yet to receive the evidence of Professor Gerada, let alone admit it in evidence or decide whether to rely upon it. He does not know what Professor Gerada's evidence is on the question whether gambling contributed to the death of Mr Adams.
52. It is rare that the Administrative Court will entertain a challenge to the exercise of a coroner's discretion whilst the colonial process is ongoing. It is rarer still that the court will consider a challenge to a case management decision whilst the proceedings are underway. Usually, the proper course is to wait until the inquest is concluded. I agree with these submissions.

Reasons

53. The Coroner stated his reasons to the interested parties for seeking to obtain expert evidence, namely, so that he could consider whether gambling or gambling addiction had causative role in the death of Mr Adams. Because the proceedings are only at case management stage, in my view, the Coroner was not required to provide full written reasons for his decision to invite Professor Gerada and Dr Frazer to give evidence. Reasons will be given for either accepting or rejecting their evidence at a later stage in the proceedings.
54. For all these reasons, permission to apply for judicial review is refused.
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