Jonathan Metzer

Inquests

Inquests in the Coroners’ Court form a significant part of Jonathan’s practice. He frequently appears in cases involving medical or psychiatric treatment, including apparent suicide, deaths on the road, and deaths in custody. He has extensive experience in witness handling, preparing written submissions, conducting Article 2 inquests, and appearing before coroners and juries.

Jonathan is recommended as a leading junior by both Chambers & Partners and the Legal 500. Recent editorial includes:

• “He was really forensic and very thorough in going through the papers. His drafting was great, as was his advocacy.” – Chambers & Partners 2026
• “Jonathan is doggedly determined to obtain the answers bereaved relatives need and is adept at flexing his approach and tacking when unexpected evidence comes to light.” – Chambers & Partners 2026
• “Jonathan’s drafting is very comprehensive. He is capable on his feet and able to adapt.” –  Chambers & Partners 2026
• “Jonathan is a thorough, considered and highly capable counsel. He has a measured and considerate manner with witnesses, giving them confidence and support.” – Chambers & Partners 2026
• ‘Jonathan is an absolute star.’ – Legal 500 2026
• “Jonathan has a unique disarming style that is very effective in engendering the confidence of the court.  He is very thorough and calm under pressure.” –  Legal 500 2025
• “Jonathan is very thorough and sensible. He has a very disarming advocacy style.” – Chambers & Partners 2025
• “Faultless at inquests.” – Chambers & Partners 2025

Selected Cases

• Two-week Article 2 inquest into death of man with Down’s syndrome held under Mental Health Act. Narrative conclusion in which jury found that the deceased died due to “inadequate weight management”, “failure to diagnose obesity hypoventilation syndrome”, “inadequate consideration of the use of promethazine” and a “failure to identify the seriousness of a life-threatening situation”. Coroner made Regulation 28 report identifying total of 16 items of concern relating to two different bodies. Instructed by the family.
• Nine-day Article 2 inquest heard before a jury. It related to the death of a man from injuries caused to him after he stole a white van and was caught by the victim and the victim’s friend. The case involved consideration of the procedure for arranging a medical assessment for an individual who enters police custody. Instructed by the healthcare provider.
• Two-day inquest into the death of a five-year old boy who drowned in the swimming pool of a holiday park in Cornwall. The Coroner made a Prevention of Future Deaths Report arising from the fact that the park operator did not provide lifeguards for the pool. Instructed by the family.
• Four-day Article 2 inquest before a jury. The deceased died in police custody from a seizure as a result of alcohol dependency, in circumstances where he was attended upon by Healthcare Professionals but was not properly assessed and his dosage of Chlordiazepoxide medication was not adjusted as it should have been. Expert evidence was heard on this. Instructed by the healthcare provider.
• Seven-day Article 2 inquest with the witnesses including five National Highways employees. Despite submissions from the family, their conduct was not criticised, but praised. The deceased walked from the M1 hard shoulder into the path of a lorry. Prior to this, he crashed his car but was assessed by National Highways officers as not being at risk if left to await recovery. Instructed by National Highways.
• Four-day The deceased died aged 32 after suffering a cerebral haemorrhage shortly after giving birth, caused by pre-eclampsia. The coroner did not find neglect, nor that death would have been averted had it not been for the error. No Prevention of Future Deaths Report was made in view of the learning that had been implemented since. Instructed by the NHS Trust.
• Four-day Article 2 inquest before a jury. A 30-year-old woman was detained in hospital under the Mental Health Act. She was allowed out unescorted for a cigarette and absconded, and was subsequently found unresponsive on a park bench. It was concluded that shortfalls in her care may have contributed to her death, including inadequate hospital drug outreach policies and education on drug misuse, and a lack of professional curiosity by members of staff. Instructed by the family.
• Article 2 inquest with jury heard over four days after deceased took own life by hanging. Narrative conclusion in which jury found that the timing of a Mental Health Act assessment was inadequate, there was a failure by the ambulance crew to initiate a risk assessment on arrival at the property and that there was widespread insufficient communication between all services. Instructed by the family.
• Four-day Article 2 inquest with jury after deceased took own life by drowning. Jury recorded causative failings by hospital mental health nurses in assessing level of risk in days leading up to the death. Instructed by the family.
• Two-day inquest into a death of an elderly woman with obesity who developed a pressure sore which became septic while she was bedbound. Acted for her GP, whom the Coroner excluded from criticism in his conclusion.
• Six-day inquest convened under Article 2 into the deaths of a married couple who were discovered with multiple stab wounds hours after the husband had been discharged from hospital after attempting suicide. Coroner recorded a narrative conclusion which included significant criticisms of the care provided at the mental health hospital trust. Instructed by the family.
• Inquest arising from death of elderly women following failure by hospital trust to arrange adequate anticoagulation follow-up, amid serious allegations of abuse by care home. Instructed by the family.
• Two-day inquest arising out of a death after 24 hours in intensive care following a failed intubation. Represented consultant intensivist who had been subject to significant but poorly-founded criticism in the hospital trust’s serious incident report.  
• Deceased died after a two-week period in hospital in which she did not receive a necessary operation to reattach her gastric feeding tube. Article 2 inquest with conclusion which included finding of neglect by hospital trust in three separate ways. Instructed by the family.
• Deceased discovered in state of asphyxiation at his local park. Conclusion of suicide recorded. Instructed by GP who had had consultation with deceased several days before his death.
• Deceased died after apparently jumping off cliff over the Port of Dover. Article 2 inquest with narrative conclusion. Coroner also wrote a letter to the Care Quality Commission regarding his concerns. Instructed by the family.