See Inquests

Case and summary Date added Categories
R (Maguire) v United Response [2019] EWHC 1232 (Admin) — "First, the claimant contends that the defendant erred in law by determining at the end of the evidence that article 2 no longer applied under Parkinson, thereby prejudging a matter that should have been left to the jury. Secondly, the Coroner erred in law by determining that the jury should not be directed to consider whether neglect should form part of their conclusion. ... That the case law has extended the positive duty beyond the criminal justice context in Osman is not in doubt. The reach of the duty, beyond what Lord Dyson called the "paradigm example" of detention, is less easy to define. We have reached the conclusion, however, that the touchstone for state responsibility has remained constant: it is whether the circumstances of the case are such as to call a state to account: Rabone, para 19, citing Powell. In the absence of either systemic dysfunction arising from a regulatory failure or a relevant assumption of responsibility in a particular case, the state will not be held accountable under article 2. ... We agree that a person who lacks capacity to make certain decisions about his or her best interests - and who is therefore subject to DOLS under the 2005 Act - does not automatically fall to be treated in the same way as Lord Dyson's paradigm example. In our judgment, each case will turn on its facts. ... [The Coroner] properly directed himself as to the appropriate test to apply to the issue of neglect and having done so declined to leave the issue to the jury." 2019‑05‑15 21:35:39 2019 cases, Cases, Inquests, Judgment available on Bailii

R (Silvera) v HM Senior Coroner for Oxfordshire [2017] EWHC 2499 (Admin) — "In this claim for judicial review Muhammad Silvera challenges the decision of the Senior Coroner for Oxfordshire not to resume the inquest into the death of his mother, Ms Vittoria Baker. It is submitted that the decision of the Senior Coroner not to resume the inquest and thereby to hold a full inquest into this death was unlawful. It is submitted that the Senior Coroner breached the investigative duty under Article 2 of the European Convention on Human Rights and was irrational and in breach of the duty at common law to fully investigate this death. ... The Senior Coroner refers in his letter of February 2016 to the 'Crown Court Trial' together with the two reports as being sufficient to satisfy Article 2 of the Convention. There was, in fact, no Crown Court trial. At an early hearing an acceptable plea was tendered and 'K' was made the subject of a hospital order. The two other investigations comprised an internal NHS Trust investigation that was carried out in private and the DHR was expressed to be private and confidential. ... In all the circumstances, this claim for judicial review should be allowed." 2017‑10‑23 22:37:24 2017 cases, Cases, Inquests, Judgment available on Bailii

R (Ferreira) v HM Senior Coroner for Inner South London [2017] EWCA Civ 31, [2017] MHLO 2 — "On 7 December 2013, Maria Ferreira, whom I shall call Maria and who had a severe mental impairment, died in an intensive care unit of King's College Hospital, London. The Senior Coroner for London Inner South, Mr Andrew Harris, is satisfied that there has to be an inquest into her death. By a written decision dated 23 January 2015, which is the subject of these judicial review proceedings, the coroner also decided that he did not need not to hold the inquest with a jury. ... A coroner is obliged to hold an inquest with a jury if a person dies in 'state detention' for the purposes of the Coroners and Justice Act 2009. The appellant is Maria's sister, Luisa Ferreira, whom I will call Luisa. She contends that, as a result of her hospital treatment, Maria had at the date of her death been deprived of her liberty for the purposes of Article 5 of the European Convention on Human Rights and that accordingly Maria was in 'state detention' when she died. ... In my judgment, the coroner's decision was correct in law. Applying Strasbourg case law, Maria was not deprived of her liberty at the date of her death because she was being treated for a physical illness and her treatment was that which it appeared to all intents would have been administered to a person who did not have her mental impairment. She was physically restricted in her movements by her physical infirmities and by the treatment she received (which for example included sedation) but the root cause of any loss of liberty was her physical condition, not any restrictions imposed by the hospital. The relevant Strasbourg case law applying in this case is limited to that explaining the exception in Article 5(1)(e), on which the Supreme Court relied in Cheshire West and Chester Council v P [2014] UKSC 19, [2014] MHLO 16, and accordingly this Court is not bound by that decision to apply the meaning of deprivation of liberty for which that decision is authority. If I am wrong on this point, I conclude that the second part of the 'acid test', namely that Maria was not free to leave, would not have been satisfied. Even if I am wrong on all these points, I would hold that as this is not a case in which Parliament requires the courts to apply the jurisprudence of the European Court of Human Rights when interpreting the words 'state detention' in the CJA 2009, and that a death in intensive care is not, in the absence of some special circumstance, a death in 'state detention' for the purposes of the CJA 2009. There is no Convention right to have an inquest held with a jury. There is no jurisprudence of the Strasbourg Court which concludes that medical treatment can constitute the deprivation of a person's liberty for Article 5 purposes. The view that it is a deprivation of liberty would appear to be unrealistic. We have moreover not been given any adequate policy reason why Parliament would have provided that the death of a person in intensive care of itself should result in an inquest with a ..→ 2017‑01‑26 15:20:11 2017 cases, Deprivation of liberty, ICLR summary, Inquests, No summary, Transcript

R (Speck) v HM Coroner for District of York [2016] EWHC 6 (Admin), [2016] MHLO 1 — "Drawing these strands together, my conclusions were as follows. First, that the duty of the coroner was limited to a duty to investigate those matters which caused, or at least arguably appeared to him to have caused or contributed to, the death. Secondly, that the claimant was unable to show even an arguable case that any body was at the material time under a duty, statutory or otherwise, to establish a health-based place of safety at a time, and in a location, such that Miss Speck could have been taken to such a facility in June 2011. Thirdly, that the claimant was therefore unable to show even an arguable case that Miss Speck's death was caused or contributed to by a breach of such a duty. Fourthly, that the coroner was therefore correct to decline to investigate issues as to the non-availability of a health-based place of safety: to have done so would have been to investigate matters which fell outside his statutory duty under section 5 of the Coroners and Justice Act 2009. Lastly, that even if I had been persuaded that it was within the coroner's discretion to investigate such matters, I would have found there was no basis on which it could be said that his decision not to do so was a perverse or otherwise unlawful exercise of that discretion." 2016‑01‑17 19:50:20 2016 cases, Inquests, No summary, Transcript

R (LF) v HM Senior Coroner for Inner South London [2015] EWHC 2990 (Admin), [2015] MHLO 76 — "Maria died while in intensive care at King's College Hospital in London ... Plainly an inquest will be held; that is not in dispute. However, by a written decision ... the Defendant Senior Coroner rejected the argument that Maria was "in state detention" at the time of her death, within the meaning of ss. 7(2)(a) and 48(1) and (2) of the Coroners and Justice Act 2009 and therefore the inquest must be held with a jury. By way of judicial review, the Claimant challenges that conclusion and contends that in the circumstances the Coroner was bound to call a jury. The sole issue for the Court is whether the Claimant's challenge is well-founded." 2015‑10‑30 22:49:39 2015 cases, ICLR summary, Inquests, Transcript

R (Letts) v The Lord Chancellor & Ors [2015] EWHC 402 (Admin), [2015] MHLO 72 — "This application for judicial review concerns the criteria applied by the Legal Aid Agency to determine whether relatives of a deceased should be granted legal aid for representation at an inquest into a death which has arisen in circumstances which might engage Article 2... What this case boiled down to was a consideration of how Article 2 applies to the suicide of mental health patients and an assessment of the (in)adequacy of the Guidance in reflecting the law. I have come to the conclusion that in one material respect the Guidance is inadequate and both incorporates an error of law and, also, provides a materially misleading impression of what the law is. ... [I]n the absence of a clear recognition that there is a category of case where the investigative duty arises quite irrespective of the existence of arguable breach by the State the Guidance is materially misleading and inaccurate." 2015‑10‑28 23:27:05 2015 cases, ICLR summary, Inquests, No summary, Transcript

R (Antoniou) v Central and North West London NHS Foundation Trust [2013] EWHC 3055 (Admin), [2013] MHLO 98 — "This claim for judicial review arises out of the suicide of Mrs Jane Antoniou... At the time she was a patient detained ... under section 3 of the Mental Health Act 1983... For the reasons given above, we have concluded that, given all the circumstances of this case, in particular the fact that there was a properly constituted and conducted Inquest, there was no obligation under Article 2 of the ECHR to have, in addition, a separate independent investigation into the death of JA, either from the outset or from any time thereafter. We have also concluded that, taken as a whole, the investigation process into the death of JA was independent, effective and prompt. Lastly, we have concluded that there was no unlawful discrimination against JA or the claimant by any of the defendants in the way that JA's death was investigated." [Summary required.] 2013‑11‑19 22:30:38 2013 cases, ICLR summary, Inquests, Transcript

Reynolds v UK 2694/08 [2012] ECHR 437, [2012] MHLO 30(1) A voluntary in-patient killed himself by breaking and jumping out of a sixth-floor window: the court held that there was an arguable claim that an operational duty under Article 2 arose to take reasonable steps to protect him from a real and immediate risk of suicide and that that duty was not fulfilled. (2) There were no domestic civil proceedings available to his mother to establish any liability and compensation due as regards the non-pecuniary damage suffered by her on her son’s death, and therefore there was a violation of Article 13 in conjunction with Article 2. In particular: (a) neither the inquest nor the internal inquiry were an effective remedy; (b) the HRA claim under Article 2 was struck out by the county court because of domestic case law at that time which required gross negligence; (c) the mother had no prospect of obtaining adequate compensation for non-pecuniary damage under the Fatal Accidents Act 1976 (she was not a dependent) or the Law Reform (Miscellaneous Provisions) Act 1934 (death was instantaneous); (d) the lack of adequate compensation would itself reduce access to the civil remedy, as the legal aid 'cost/benefit analysis' would not be met and legal fees were unaffordable. (3) It was not necessary to examine the same complaint under Article 2 alone. (4) €7000 compensation was awarded. 2012‑03‑24 15:14:48 2012 cases, Brief summary, Inquests, Miscellaneous, Transcript

Rabone v Pennine Care NHS Foundation Trust [2012] UKSC 2, [2012] MHLO 6(1) The operational obligation under Article 2 can in principle be owed to a hospital patient who is mentally ill, but who is not detained under the MHA. (2) There was a 'real and immediate' risk to the patient's life of which the Trust knew or ought to have known and which it failed to take reasonable steps to avoid, so the obligation was breached. (3) The patient's parents were 'victims' within the meaning of Article 34 of the Convention. (4) They had not lost their victim status by settling a negligence claim, as (although it had in substance acknowledged its breach) the Trust had not made adequate redress. (5) The one-year limitation period in s7(5) HRA 1998 was extended becuase the extension was short, the Trust suffered no prejudice, the claimants acted reasonably in delaying, and there was a good claim. (6) The Court of Appeal's assessment of damages was upheld, and £5000 was awarded to each parent. 2012‑02‑08 12:33:14 2012 cases, Brief summary, ICLR summary, Inquests, Transcript

R (Smith) v Secretary of State for Defence [2010] UKSC 29 — The ECHR does not apply to soldiers serving abroad. 2010‑07‑09 20:36:58 2010 cases, Detailed summary, ICLR summary, Inquests, Transcript

Rabone v Pennine Care NHS Trust [2010] EWCA Civ 698Health trusts do not have the Article 2 operational obligation to voluntary patients in hospital, who are suffering from physical or mental illness, even where there is a "real and immediate" risk of death. [Caution.] 2010‑07‑08 22:17:17 2010 cases, Detailed summary, ICLR summary, Inquests, Transcript

R (Pounder) v HM Coroner for North and South Districts of Durham and Darlington [2010] EWHC 328 (Admin) — Inquiry into Adam Rickwood's death in custody. Bias. [Summary required.] 2010‑03‑02 20:48:52 2010 cases, Inquests, No summary, Transcript

R (P) v HM Coroner for the District of Avon [2009] EWCA Civ 1367In this inquest to which Article 2 applied (suicide in prison) the Deputy Coroner misdirected the jury because she did not properly explain to them that, if they returned a verdict of suicide or accident, they could also append a narrative about the circumstances of the accident. However, in the circumstances, the verdict was not quashed. 2009‑12‑23 18:59:49 2009 cases, Brief summary, Inquests, Transcript

R (Lewis) v HM Coroner for the Mid and North Division of the County of Shropshire [2009] EWCA Civ 1403A coroner is not obliged to leave to the jury a fact or circumstance which could have caused or contributed to the death but cannot be shown probably to have done so. 2009‑12‑23 16:21:27 2009 cases, Brief summary, Inquests, Transcript

Hurst v UK 42577/07 [2009] ECHR 1988Statement of facts and questions lodged with the court (case relates to Article 2-compliant inquests). 2009‑12‑04 21:05:43 2009 cases, Brief summary, ECHR, Inquests, Transcript

R (Hurst) v Commissioner of Police of the Metropolis [2007] UKHL 13No need to hold Article 2-compliant inquest when death occurred before implementation of Human Rights Act 1998. 2009‑12‑04 21:00:19 2007 cases, Brief summary, Inquests, Transcript

Re Maughland (Determination Into the Death of) [2003] ScotSC 10 — [Summary required.] 2009‑11‑30 22:52:01 2003 cases, Inquests, No summary, Scottish cases, Transcript

Rabone v Pennine Care NHS Trust [2009] EWHC 1827 (QB)The Article 2 "Osman" operational obligation to protect life applied to detained patients, but not to the claimant who was an informal patient on leave from the hospital at the time she committed suicide. [Caution.] 2009‑08‑01 17:59:57 2009 cases, Brief summary, Inquests, Transcript

R (P) v SSJ [2009] EWCA Civ 701The refusal of the SSJ to hold an inquiry into P's detention in YOI Feltham was lawful: (1) Article 2 is only engaged where there is a "real and immediate" risk to life; the risk from P's self harming, while real, was not immediate. (2) There was no arguable breach of Article 3 in the delay in transfer to hospital. Had there been an arguable Article 3 breach: in general, an inquiry would not have been mandatory; in this particular case, it would not have been necessary as the relevant facts were known. 2009‑07‑09 21:47:53 2009 cases, Brief summary, ICLR summary, Inquests, Transcript

R (Farah) v HM Coroner for the Southampton and New Forest District of Hampshire [2009] EWHC 1605 (Admin)(a) A coroner sitting without a jury is entitled to give a verdict and a judgment dealing with the stipulated issues which are (i) who the deceased was; (ii) how, when, by what means and in what circumstances and where the deceased came by is death; and (iii) the particulars for the time being required by the Registration Act to be registered concerning the death; (b) A coroner is entitled to give a judgment on matters which arise during the inquest and which are relevant to the determination of the stipulated issues; (c) The Court has jurisdiction which should be sparingly exercised to declare comments made by a coroner as being unlawful. Such a declaration may be made if the comments (i) do not relate to any of the stipulated issues in any way; (ii) are matters of opinion; and (iii) are sufficiently unfairly critical and offensive of any party; (d) Declarations should be made that comments made by the defendant coroner in his judgment in respect of [various matters] are unlawful. 2009‑07‑05 17:47:25 2009 cases, Brief summary, Inquests, Transcript

R (Allen) v HM Coroner for Inner North London [2009] EWCA Civ 623An inquest into the death of a patient who was detained in a hospital under s3 had to satisfy the enhanced requirements of Article 2 2009‑07‑05 17:10:55 2009 cases, Detailed summary, ICLR summary, Inquests, Transcript

Roach v Home Office [2009] EWHC 312 (QB)The costs of attending an inquest can in principle be recovered by way of costs in subsequent civil proceedings; the fact that the inquest work was covered by a public funding certificate had no bearing on the recoverability of the costs. 2009‑06‑15 19:27:35 2009 cases, Brief summary, Inquests, Transcript

R (Smith) v Secretary of State for Defence [2009] EWCA Civ 441(1) A British soldier who is on military service in Iraq is subject to the jurisdiction of the UK within the meaning of Article 1 of the Convention, so as to benefit from the rights guaranteed by the HRA while operating in Iraq, and not only when he is on a British military base or in a British hospital. (2) The inquest into the claimant's death must confirm with Article 2 standards in the scope of the investigation and nature of the verdict. 2009‑05‑18 22:38:59 2009 cases, Brief summary, Inquests, Transcript

R (Lewis) v HM Coroner for the Mid and North Division of the County of Shropshire [2009] EWHC 661 (Admin) — Coroners' inquests - deaths in custody - Article 2 2009‑04‑26 09:50:48 2009 cases, Inquests, No summary, Transcript

Platts v Coroner for South Yorkshire (East District) [2008] EWHC 2502 (Admin) — Inquest into suicide of person with mental disorder - scope of inquest and Article 2 - whether former girlfriend was properly interested person 2009‑04‑18 11:32:49 2008 cases, Inquests, No summary, Transcript

R (Takoushis) v HM Coroner for Inner North London [2005] EWCA Civ 1440Where a person dies as a result of what is arguably medical negligence in an NHS hospital, the state must have a system which provides for the practical and effective investigation of the facts and for the determination of civil liability. Unlike in the cases of death in custody, the system does not have to provide for an investigation initiated by the state but may include such an investigation. The present system complied with Article 2. Inquest verdict quashed and new inquest ordered. 2009‑04‑12 22:13:23 2005 cases, Detailed summary, Inquests, Miscellaneous, Transcript

R (Takoushis) v HM Coroner for Inner North London [2004] EWHC 2922 (Admin) — Coroner's decision not to call jury or adjourn for expert evidence, and inquest verdict, were lawful. [Overturned on appeal.] 2009‑04‑12 22:13:22 2004 cases, Inquests, Miscellaneous, No summary, Transcript

Edwards v UK 46477/99 [2002] ECHR 303Christopher Edwards was killed by a prison cellmate, Richard Linford; both suffered from schizophrenia. (1) The duty under Article 2 to protect life could extend to taking preventive operational measures to protect an individual against criminal acts of another, where the authorities knew (or ought to have known) of a real and immediate risk to the life of an identified individual. Information was available identifying Linford as posing such a risk. The failure to pass on this information, and the inadequate screening of Linford, amounted to a breach of Article 2. (2) No inquest was held, and the trial did not involve witness evidence. The private inquiry which was held (a) had no power to compel witnesses, and (b) was held in private, with the parents unable to participate to the extent necessary to safeguard their interests: Article 2 was breached in this respect. (3) There was no appropriate domestic means of determining whether the authorities failed to protect the right to life or of obtaining compensation, so Article 13 (effective remedy) was breached. 2008‑11‑27 23:17:24 2002 cases, Brief summary, Inquests, Transcript

R (Anderson) v HM Coroner for Inner North Greater London [2004] EWHC 2729 (Admin) — Unlawful killing verdict relating to restraint while subject to s136 MHA 1983 quashed. 2008‑10‑15 19:23:00 2004 cases, Inquests, No summary, Transcript

Michael Stone v South East Coast Strategic Health Authority [2006] EWHC 1668 (Admin)The public interest required publication in full of the Michael Stone inquest report; the decision to publish was justified and proportionate, and did not constitute an unwarranted interference with Article 8; no breach of the DPA was involved. 2008‑02‑22 16:15:56 2006 cases, Brief summary, Inquests, Transcript

Article titles

The following 31 pages are in this category.