UK: Inquests

The obligation for the state to ensure a properly independent investigation is carried out where any of the substantive obligations may have been violated is also imposed by Article 2. The House of Lords considered whether the existing procedures to return verdicts under the jurisdiction of the Coroner’s Court provided sufficient investigation of a death involving or possibly involving a violation of Article 2.

The background to the case was the death of Mr Middleton who had killed himself while serving a prison sentence. In the inquest into his death the jury delivered a verdict of suicide but were not allowed, due to restrictions imposed by the Coroners Rules, to add publicly that failings in the system had contributed to his death. The deceased’s wife had sought an order that the jury’s findings be publicly recorded.

Lord Bingham, delivering the court’s judgment, expressed the view that a verdict of an inquest jury which did not express the jury’s conclusion on a major issue canvassed in the evidence given at the inquest could not meet the expectations of the deceased’s family or next of kin who themselves had legitimate interests in the investigation into the death. The court indicated that "an inquest ought ordinarily to culminate in an expression, however brief, of the jury’s conclusion on the disputed factual issues at the heart of the case".

The Coroners Rules require juries to set out in writing who the deceased was and how, when and where he came by his death, but do not allow the jury to express an opinion on any other matter. The court held that a broad interpretation of "how" the deceased came to his death accorded with the HRA and in order to comply with the requirements of Article 2, juries should now determine "in what circumstances" the deceased had died as well as "by what means". This opens the doors for juries to express a view on disputed factual issues raised in the inquest.

• Juries can now return narrative verdicts which might identify individual or systematic failings, whilst remaining bound by the rules that the verdict should not reach a finding of criminal or civil liability in respect of any named person. The court cautioned against using words such as "neglect" or "carelessness".

• The Coroner’s powers to make recommendations of precautions to prevent repetition of any event that has come to light as a result of the inquest is not altered other than any recommendations made can now be stated publicly.

• Although this case specifically relates to a death in custody, it will be interesting to see the implications of the judgment for the conduct of inquests generally. All parties represented at an inquest will now be required to ensure a full examination of the evidence surrounding the death is undertaken and it is more likely that it will be necessary to make detailed submissions regarding the circumstances leading up to the death of patients who have died in NHS hospitals (or private hospitals where the patient has been placed by the local authority), whether or not they are detained under the Mental Health Act.

Our experience since the ruling of the House of Lords is that inquests are now more likely to take the form of a thorough investigation into all the circumstances leading to the death, although much will depend on the discretion of individual coroners.

© RadcliffesLeBrasseur

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