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R v HM Deputy Coroner for Birmingham, Court of Appeal, 2 December 2003

10 December 2003
The issues

Human Rights – Article II – Right to Life – Coroners

The facts

Darren Davies was sent to Winson Green Prison in Birmingham in March 2001. He had admitted having taken heroine and complaining of aches and pains. He was prescribed a detoxification drug treatment taken over a period of 4 days. On 5th March he died having been unwell for several days over the intervening period. On the Friday before the Monday on which he died his sister had rung the Prison to check whether her brother was receiving medication and was told by the nurse who took the call that she was in no position to check whether he had received his dose or not since the staff could not check on everyone. Dr Rally, from another prison provided an independent report which noted that the onus was placed on Darren to seek treatment and further help; that no-one checked to see why he did not attend for treatment; that whilst practices were in place for those considered to be at risk if they did not receive treatment in respect of diabetics and those on heart medicine, those practices did not extent to drug users; that if his case had been followed up it might have prevented his deterioration; that his condition on the Sunday night before he died was unusual and that the nurse did not obtain all the available information or discuss the case with the Duty Doctor; that the Nurse should have been able to move him to an area for closer healthcare supervision and that Darren’s collapse in the early hours of Monday morning was unusual and should again have led to discussion with the Duty Doctor. The last three points were not allowed to go before the Jury when the matter came before the Coroner. After a 5-day Hearing the Jury returned a verdict of accidental death. Darren’s mother sought judicial review of the Coroner’s decision, alleging that he failed properly to direct the Jury to the meaning of neglect, failed to admit the evidence from Dr Rally and failed adequately to leave to the Jury the decision as to whether the system for his care on or after admission was defective. The matter came before the High Court Judge who dismissed the Application for Judicial Review. The Claimant’s mother appealed to the Court of Appeal.

The decision

The law with regard to Coroners was in an unsettled state but it was now clear that the English coronial system as presently constituted was an inadequate vehicle for the procedural obligations imposed by Article 2 of the European Convention on Human Rights (right to life). Both law and procedure were in serious need of reform.

After the previous decisions of Middleton about which serious anxieties had been expressed and the decision of the House of Lords in Amin, the law now stood as follows:-

(i) There had to be a full and effective enquiry into the death at a Coroners Inquest if this was realistically that the only occasion on which the state would perform its procedural duty.

(ii) It was open to the Jury to return a verdict incorporating a finding of neglect in a broader range of circumstances than those contemplated in previous cases if the verdict related to systemic neglect.

(iii) A letter written by a Coroner pursuant to Rule 43 was not an adequate substitute for the purposes of Article 2 for the verdict by the jury in cases where a verdict of neglect was available on the evidence.

(iv) The appeal would be allowed and the inquisition quashed. Unless an enquiry was set up to perform the same function as an inquest but had more appropriate powers the Coroner had to hold a new Inquest and it would be essential that he held an early Case Management Conference at which consideration could be given as to the best way to manage the giving of oral evidence. The new enquiry had to determine whether systemic neglect was a contributory cause to the death and the evidence should be primarily directed to that issue.

Appeal allowed.

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