Imelda Quinto Abong v Coroner

Mimmie Chan J
8, 15 April 2021


On a mid-morning in April 2017, the deceased, aged 46, was found in an unresponsive state in her room at the flat where she had been employed as a domestic helper since December 2016. She was taken to hospital where she was certified dead in the early afternoon of that day. An autopsy performed two weeks later left the cause of the deceased’s death as “unknown”. The Coroner certified three days later that the precise medical cause of death had yet to be established. A report issued by the Government Laboratory in May 2017 stated that no significant finding was obtained from screening of the deceased’s blood and urine. In July 2017, the Coroner directed the police to report on the deceased’s death. By a report in April 2018, the police said that their investigations revealed no particular sign of suspicion or crime, and recommended that no inquest into the deceased’s death be held. In March 2019, the Coroner issued a death report stating a decision that no inquest into the deceased’s death was required and that her death should be classified as being of “unknown causes”. X was a sister of the deceased. On the basis of what she said that the deceased had told her, X made complaints about the deceased’s conditions of work. The Coroner issued instructions in November 2019 for the obtaining of a statement from the deceased’s employer, and of a medical report from the hospital, on the prior state of the deceased’s health. That did not lead to any cause of death being discovered. X applied under s.20(1)(a) of the Coroners Ordinance (Cap.504) (the Ordinance) for an order that an inquest be held into the death of the deceased.

Held, ordering that an inquest be held into the deceased’s death, that:

  1. By reason of s.27(b) of the Ordinance the purposes for which an inquest was held include ascertaining “how” a person came by his death. Under s.20(1)(a), the court had to consider whether an inquest “ought to be held”, not whether a coroner made any particular error in reaching a decision not to hold an inquest (Secretary for Justice v Coroner [2011] 1 HKLRD 283 applied).
  2. An inquest was inquisitorial.
  3. “How” a person came by his death was wider than the medical cause of death. It extended to acts and omissions directly responsible for the death and to by what means and in what circumstances a person came by his death (R v HM Coroner for North Humberside and Scunthorpe [1995] QB 1, R (Middleton) v West Somerset Coroner [2004] UKHL 10, Sony Rai v Coroner [2011] 2 HKLRD 245 applied; Tien v Lam Esq [2004] 2 HKLRD 719, Secretary for Justice v Coroner [2011] 1 HKLRD 283 considered).
  4. On the evidence presently available, the deceased was, at the time when she died suddenly, still relatively young and not suffering from any illness that could have caused her death. No pathological or toxicological basis accounting for her death had been found. There was evidence that she had been complaining about her conditions of work which included overwork, malnourishment and abuse.
  5. Public interest considerations arose where a person in a vulnerable and dependent situation died in the care and custody of an employer and the death was unaccounted for and could not be explained. A coroner’s court was empowered by s.44(2) to make recommendations designed: to prevent recurrence of similar fatalities; to prevent other hazards to life disclosed by the evidence at the inquest; and to draw to the attention of those who may have power to take appropriate action any deficiencies in a system or method of work which were disclosed by the evidence at the inquest and were of public concern.
  6. There was evidence of a systemic deficiency in how the police investigate when foreign domestic helpers or their family members sought help. Whether the applicant’s reports and complaints were true or exaggerated could be examined at an inquest. In all the circumstances, an inquest ought to be held into the cause of, and the circumstances connected with, the deceased’s death.


This was an application under s.20 of the Coroners Ordinance (Cap.504) for an order that an inquest be held into a person’s death.

Editorial Note: Albeit only with the benefit of argument from one side, this judgment deals extensively with the nature and purposes of a coroner’s inquest.