Coroners’ courts – Death in custody – Inquests

R (on the application of Keith Lewis) (appellant) v HM Coroner for the Mid and North Division of the County of Shropshire (respondent) and Secretary of State for Justice (interested party): CA (Civ Div): (Lords Justice Sedley, Rimer, Etherton): 21 December 2009

The appellant father (F) appealed against a decision ([2009] EWHC 661 (Admin), [2009] 108 BMLR 87) that the respondent coroner had not unlawfully omitted an issue to be considered by a jury during an inquest concerning the death of an individual (L) in a young offender institution.

L had been sentenced to detention in the institution. An officer on night patrol (K) later found him hanging from a light fitting in his cell. K had not received training in suicide prevention or first aid, he did not open the cell and did not have a tool to cut L down. He called for assistance, but only indicated that there were breathing problems and so assistance arrived later than it should have. When L was cut down he was dead. At the inquest, the coroner identified issues to be addressed in the proceedings. A questionnaire was presented to the jurors in which they were told to only answer the questions if they believed that, either on its own or with others, an act or omission had caused or contributed to L’s death. That questionnaire was later incorporated in the coroner’s verdict when setting out the jury’s conclusion that L had hanged himself, intending to take his life. However, one issue, namely the action taken after L had been found hanging, had been omitted in the questionnaire. The issue was also omitted from the coroner’s report, made under rule 43 of the Coroners Rules 1984 and submitted to the ­relevant authorities. F submitted that for the jury’s verdict to be required on a fact or circumstance it did not have to have been a probable cause of or contributor to the death, so long as it was capable of being such.

Held: Article 2 of the European Convention on Human Rights 1950 required the state not only to abstain from taking life, except as the article allowed, but also to investigate impartially and diligently any death occurring at or in its hands. The omission in the report of details of action taken after L had been found hanging in his cell was a breach of rule 43. There was a want of equipment, training and effective procedure which the undisputed evidence revealed was so eloquent of action that needed to be taken to prevent similar fatalities that the coroner could not have believed otherwise. Once it was established that the facts about K’s equipment, training and use of procedure were so clearly relevant to the possible occurrence of further prison deaths that the coroner was obliged by rule 43 to report on them, the requirements of article 2 were satisfied, E v United Kingdom (33218/96) (2003) 1 FLR 348 ECHR considered. It could intelligibly be said that, in a jurisdiction which was not concerned with the allocation of blame, potentially causative circumstances could be just as relevant as actually causative ones. However, the present legislative allocations of functions between coroner and jury, properly interpreted and properly implemented, would fulfil the functions which were required by the convention to be fulfilled, R (on the application of Middleton) v HM Coroner for Western Somerset [2004] UKHL 10, [2004] 2 AC 182 considered.

Appeal dismissed.

Tim Owen QC, Paul Bowen (instructed by Bhatt Murphy) for the appellant; Jonathan Hough (instructed by in-house solicitor) for the respondent; Jenni Richards, Colin Thomann (instructed by Treasury Solicitor) for the interested party.