R (Boyce) v HM Senior Coroner for Teesside and Hartlepool [2022] EWHC 107 (Admin)

Inquest and care order (1) There was no procedural obligation to hold an Article 2 Middleton inquest into the death of the child who was under a care order in a residential children's home, as she was not in state detention: the difference between a child deprived of liberty in secure accommodation, and a child in care who is free to come and go (notwithstanding that if she simply left police would have been called to return her) and for whom there was no suggestion of secure accommodation, is of substance not merely of form. Obiter, even if the child had been detained it would not have been pursuant to any action by the state given the private nature of the accommodation. (2) The coroner was not wrong to conclude that on the available material there was no arguable breach of the Article 2 general/systems duty. (3) The argument that the coroner had been wrong to hold that the only material effect of the inquest not being an Article 2 inquest would be on the conclusions that might be returned, rather than upon the scope of the inquest, was also unsuccessful.

Essex search

This case's neutral citation number appears in the following newsletters:


The ICLR have kindly agreed for their WLR (D) case report to be reproduced below. For full details, see their index card for this case.  

The WLR Daily case summaries

[2022] WLR(D) 42B

Queen’s Bench Division

Regina (Boyce) v Teesside and Hartlepool Senior Coroner

[2022] EWHC 107 (Admin)B

2021 Dec 14; 2022 Jan 21

Judge Belcher sitting as a High Court judge

Coroner— Inquest— Scope of inquest— Death of child in care— Coroner deciding not to conduct enhanced investigation into death— Whether child in care analogous to person in detention— Whether coroner under duty to conduct enhanced investigation— Children Act 1989 (c 41), s 31 — Human Rights Act 1998 (c 42), Sch 1, Pt I, art 2 — Coroners and Justice Act 2009 (c 25), s 5

While in the care of the local authority pursuant to a care order under section 31 of the Children Act 1989, the claimant’s daughter died in her room at a small residential home for young people with complex behavioural needs where she had been placed temporarily. The coroner determined that the inquest into the child’s death under section 5 of the Coroners and Justice Act 2009 should not be a full inquest engaging the “enhanced investigative duty” under article 2 of the Convention for the Protection of Human Rights and Fundamental Freedoms (which, if engaged, would have required the question of “how” the deceased came by her death, under section 5(1) of the 2009 Act, to be answered by considering not only by what means she had met her death but also in what circumstances). However, the coroner observed that the only material effect of the inquest not being an article 2 inquest was on the conclusions that could be returned, rather than on the scope of the inquest itself. The claimant sought judicial review of the coroner’s decision contending, inter alia, that an article 2 inquest was automatically triggered because the claimant’s daughter, as a child in the care of the local authority, was in an analogous position to a person in state detention.

On the claim—

Held, claim dismissed. (1) While there was no dispute that article 2 of the Human Rights Convention extended to all violent deaths and suicides of persons in state detention, such that a full article 2 inquest would follow automatically in such circumstances, the position of the claimant’s daughter was not analogous. There was a very real and obvious difference of substance, not merely one of form, between a child in secure accommodation who had thereby been deprived of her liberty and a child in care such as the claimant’s daughter who was free to come and go, notwithstanding that if she simply left the home police assistance would have been sought to find and return her. It was relevant in that regard that the child had been free to leave the residential home to attend school and there was no suggestion that she was deprived of her liberty at school, that she was not locked into her room but rather, by locking it from the inside, had the liberty to exclude others, which was not consistent with the submission that she was under constant supervision and control, and that she was not the subject of a secure accommodation order nor was there any suggestion that she should have been in secure accommodation. No automatic duty to conduct an article 2 enhanced investigative inquest arose simply by reason of her being a child in care who sadly took her own life (paras (12, 32–34, 36).

Dicta of Popplewell LJ in R (Morahan) v West London Assistant Coroner [2021] QB 1205B, para 122, DC applied.

Dicta of Lord Dyson JSC in Rabone v Pennine Care NHS Foundation Trust [2012] 2 AC 72B, paras 27–30, SC(E), dicta of Baroness Hale of Richmond DPS in Surrey County Council v P [2014] AC 896B, paras 46, 49, SC(E) and R (Ferreira) v Inner South London Senior Coroner [2018] QB 487B, CA considered.

(2) Having determined that there was no breach of the operational duty under article 2, and while accepting that there were clearly issues with the systems and procedures operated by the local authority’s social services department and by the residential home, the coroner had been entitled to conclude, despite the apparently serious systemic breaches disclosed, that in light of the high standard and high level of the care that the claimant’s daughter was in fact receiving it was not arguable that improved systems and procedures would have presented her with a real and substantial chance of survival. It followed that the coroner had not erred in concluding that there was no arguable challenge based on systemic breaches of article 2 (paras 6, 8, 41, 42, 59, 60).

(3) It was plain from an analysis of the authorities that, notwithstanding that the natural reading of sections 5(1) and 5(2) of the 2009 Act tended to suggest there was a difference in scope of the two types of inquest, in practice that was not the situation. The practical solution was for inquests to address the broad circumstances especially if there was a possibility that article 2 might become relevant in the future. In those circumstances the inquiry ought to be broad enough to cover the ground for the coroner or jury to make the necessary conclusions. In the present case, the coroner had not erred in expressly recognising that possibility, which would inevitably feed into her decisions as to scope generally, whether in relation to the scope of questions, disclosure or verdicts (para 74).

Dicta of Hallett LJ in R (Sreedharan) v Manchester City Coroner [2013] Inquest LR 42, para 18(vii), CA and dicta of Lord Burnett of Maldon CJ in R (Maguire) v Blackpool and Fylde Senior Coroner [2021] QB 409B, para 77, CA considered.

Dr Anton van Dellen (instructed by Watson Woodhouse Solicitors LLP, Middlesbrough) for the claimant.

Jonathan Hough QC (instructed by Legal and Governance Services, Middlesbrough Council) for the coroner.

Jonathan Walker (instructed by Legal and Democratic Department, Middlesbrough Council) for the local authority.

Sam Faulks (instructed by Taylor Law, Middlesbrough) for the residential home provider.

Jeanette Burn, Barrister

Referenced Legislation

Children Act 1989 (c 41), s 31

Human Rights Act 1998 (c 42), Sch 1, Pt I, art 2

Coroners and Justice Act 2009 (c 25), s 5


Full judgment: BAILII


Date: 21/1/22🔍

Court: High Court (Administrative Court)🔍




  • Kelly Anne Boyce🔍
  • HM Senior Coroner for Teesside and Hartlepool🔍
  • Middlesbrough Borough Council🔍
  • Tees Valley Care Ltd🔍

Citation number(s):

What links here:

Published: 10/2/22 21:37

Cached: 2024-04-13 08:56:37