R (Speck) v HM Coroner for District of York  EWHC 6 (Admin),  MHLO 1
The WLR Daily case summaries
 WLR (D) 7
Queen’s Bench Division
Regina (Speck) v HM Coroner for the District of York
2015 Nov 11; 2016 Jan 12
Sir Brian Leveson P, Holroyde J
Coroner — Inquest — Coroner’s duties — Scope of duty to investigate death in custody — Whether duty to investigate matters which might possibly have contributed to death — Whether duty to investigate whether absence of provision of place safety contributing to death — Mental Health Act 1983 (c 20), s 136(1) — Human Rights Act 1998 (c 42), Sch 1, Pt I, art 2 — Coroners and Justice Act 2009 (c 25), s 5
The police removed the deceased to a local police station, as a consequence of her behaving erratically in a public place, pursuant to powers in section 136(1) of the Mental Health Act 1983, and placed her in a police cell where she was later found dead. The coroner determined at a preliminary inquest hearing that issues as to why the local authority did not have in place a more appropriate designated health-based place of safety to which she could alternatively have been removed, and perhaps treated, fell outside the scope of the inquest as being too far removed from causation as provided by section 5 of the Coroners and Justice Act 2009. The claimant, the deceased’s mother, sought judicial review of the coroner’s ruling, contending, inter alia, that the primary care trust had had a duty to provide a health-based place of safety and that the coroner had wrongly excluded consideration of the issue whether the absence of a place of safety had contributed to the deceased’s death. It was common ground that article 2 of the Convention for the Protection of Human Rights and Fundamental Freedoms was engaged, such that the state’s procedural obligation to investigate the death applied. The application for permission to proceed with the claim was heard with the substantive claim to follow, if granted.
Permission to proceed with the claim for judicial review refused. (i) Section 5 of and paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 plainly prescribed certain matters which it was the purpose of an inquest to investigate, and those on which the coroner or the jury had not to express an opinion. The effect was to divide potential issues into three categories: those which the coroner had to investigate; those which the coroner had a discretion to investigate; and those which the coroner was not permitted to investigate. (ii) Having regard to established law, a coroner conducting an article 2 inquest had a discretion to investigate matters which might possibly have contributed to the death but was obliged to investigate those matters which caused, or at least arguably appeared to have caused or contributed to, the death. Therefore, a coroner determining the scope of an inquest was entitled to conclude that a particular issue was so remote from the causes of the death that it could not arguably be said to have contributed to the death and, on that ground, to exclude it from consideration. The coroner was entitled to distinguish between issues which at least arguably might prove to have been contributory factors in the death and those which could not even be said to have made any real contribution to the death. Having drawn that distinction the coroner might decide in the exercise of his discretion to investigate the former; but had no discretion to investigate the latter. (iii) The claimant had been unable to show that, at the material time, any body was, even arguably, under a duty to establish a place of safety at a time, and in a place, such that the deceased could have been taken to it when detained. It followed that the claimant had also been unable to show, even arguably, that the fact that there was no place of safety at the material time was in itself evidence of a breach of duty, causative of or contributing to the death, which the coroner was required, or had a discretion, to investigate. The coroner had therefore been correct to decline to investigate issues as to the non-availability of a place of safety, since to have done so would have been to investigate matters which fell outside his statutory duty under section 5 of the 2009 Act (paras 22, 28, 38, 39, 47, 48, 49).
John-Paul Swoboda (instructed by Ardent Law, York) for the claimant.
Michael O’Brien QC (instructed by Solicitor, York City Council, York) for the coroner.
Michael Rawlinson (instructed by DAC Beachcroft LLP) for NHS England, the first interested party.
Sarah Knight solicitor (of Bevan Brittan LLP) for MEDACS, the second interested party.
Thomas Barnes, Solicitor