A Norfolk man who has fought to discover the full truth about his step-daughter’s mysterious death, has won the right for a fresh inquest be held.

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Shop worker Joanne Foreman, 41, was found dead in March 2011 at her home in St Helena Way, Horsford, Norfolk, and more than three years on, the authorities are still no closer to finding out how she died.

Her step-father, Andrew Brown, 68, told the High Court he had devoted “hundreds of hours” to the task of finding answers and succeeded in uncovering a fatal flaw in the “inadequate” police investigation into his step-daughter’s death.

An inquest was held in September 2011 and Norfolk coroner, William Armstrong, specifically excluded the possibility that Joanne had been unlawfully killed or that she had taken her own life.

In a narrative verdict, he said he could not be sure what killed her but found that ‘there existed a real possibility’ that she had injected herself with her diabetic 15-year-old son’s insulin and that that, combined with alcohol, may have caused her death.

Lord Justice Pitchford today told the High Court that it was now agreed on all sides that the police investigation into Joanne’s death was inadequate.

Evidence that has come to light since the inquest had ‘effectively eliminated’ the possibility that insulin played any significant part in Joanne’s death and the judge said that the entire inquest had therefore proceeded on a ‘mistaken assumption’.

The judge, sitting with Judge Peter Thornton QC, said: “While it is not possible to conclude that the verdict following a fresh inquest is likely to be different, I have reached the conclusion that, upon this common ground alone, it is in the interests of justice that a new inquest should be held.

“It is on the facts of this case a denial of justice that there remain public findings by the coroner which are known to be inaccurate in a material respect.”

Mr Brown, who represented himself in court, had “insisted upon advancing his assertion that Norfolk Constabulary and others have relentlessly pursued an attempt to cover up the deficiencies in the original investigation, to ‘rig’ the coroner’s inquest and to deny Joanne’s family access to information”.

However, after a detailed trawl through the evidence, the judge “unhesitatingly” rejected Mr Brown’s assertions of misconduct and dishonesty by the police, an expert witness in the case and the coroner himself.

Although there was no doubt that the information put before the coroner was ‘incomplete and inadequate’, and that the inquest was ‘was less than satisfactory’, that did not mean that anyone had acted dishonestly.

However, the judge accepted that, had Joanne’s death been treated as ‘suspicious’ from the outset, a full forensic post mortem and scene of crime procedures would have been carried out.

And he observed: “The fact that this did not occur has resulted in unmerited speculation as to the possible causes of Joanne’s death.’

Mr Brown, a retired businessman, had claimed that Joanne’s body was released for cremation ‘despite his protestations’ and ‘he felt strongly that there was a reluctance among the officers involved to get to the bottom of Joanne’s death.’

He complained that he had not received copies of post-mortem and toxicology reports and Lord Justice Pitchford acknowledged that it was ‘entirely understandable’ that he had ‘felt marginalised’ from the investigation and the inquest process.

Judge Thornton agreed that a fresh inquest had to be held.

He said: “As a result of the blood sugar level finding of the paramedics not being available to the coroner, the medical side of the investigation into the sad death of Joanne Foreman set off in the wrong direction and never got back on track”.

Although he agreed that Mr Brown’s assertions of collusion and conspiracy between the police the coroner were ‘without foundation’, he concluded that the deficiencies in the inquest were “so significant that it is necessary and desirable in the interests of justice that a fresh investigation and inquest be held.”

Joanne, who worked as a floor manager for H&M, was found collapsed in bed by her partner, Adrian Gayton, who tried to rouse her as she was late for work. Mr Gayton told the inquest that he immediately dialled 999 before making a futile bid to resuscitate her. She was pronounced dead at the scene.

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