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R (Middleton) v West Somerset Coroner, House of Lords, 11 March 2004

18 March 2004
The issues

Coroner – State’s duty to investigate death – Human Rights Act 1982 – Article 2.

The facts

Colin Middleton hanged himself in his cell at HMP Horfield on 14th January 1999. He had been in custody since the age of 14 when he had been convicted of murder. He had a history of self-harm in prison. At the time of his death there was evidence that he was depressed and he was receiving medication. He had written to the Wing Governor unhappy about his status and referring to his mental illness and had spoken to another prisoner about this condition. Although only 30 he had spent more than half his life in custody. The first Inquest into his death was quashed for want of sufficient inquiry. The second Inquest was held over 3 days in October 2000 when evidence had was received from 11 witnesses and written evidence from a further 7. That investigation was accepted by the family to have been thorough, effective and sensitive in its exploration of the issues. The Coroner had ruled that the issue of “neglect” should not be left to the Jury but he told the Jury that if they wished they could give him a note regarding any specific areas of the evidence about which they were concerned and he would consider the note when considering the exercise of his power under Rule 43 to bring matters to the attention of the appropriate authorities. The Jury found the cause of death to be hanging and returned a verdict that he had taken his own life from the balance of his mind being disturbed. They took the opportunity offered to them by the Coroner of sending the Coroner a note in which they expressed concern about the manner in which Mr Middleton had been treated. In exercising his power under Rule 43 the Coroner wrote a full letter to the Chief Inspector of Prisons drawing attention to the Jury’s concerns and pointing out that on the day before his death the deceased had not left his cell even for meals and had placed a rug all day over the inspection port window into the cell.

Mrs Middleton sought an Order that the Jury’s findings as set out in the note, be publicly recorded and that there should therefore be a formal public determination of the responsibility of the prison service for the death of the deceased. The matter became before the High Court Judge who concluded that an Inquest would not necessarily satisfy the procedural requirements of Article 2 but declined to order that the Jury’s note be incorporated into the Inquisition for various reasons but most importantly because he considered that the Coroner had acted unlawfully in suggesting production of the note. He considered that no declaration was needed but, at the request of the Secretary of State, declared that by reason of the restrictions on the verdict that the Inquest was inadequate to meet the procedural obligation in Article 2 of the European Convention. The matter came to the Court of Appeal on the Secretary of State’s Appeal. The Court of Appeal found that to comply with Article 2, a verdict of neglect be available but distinguished between individual and systemic neglect, noting the particular importance of identifying systemic neglect for the purpose of vindicating the right to life protected by Article 2. The Court of Appeal set aside the Judge’s declaration and declared that in a case where a Coroner knows that it is the Inquest which is in practice the way the State is to fulfil the obligation under Article 2 of the European Convention of Human Rights, and that the finding of neglect by the Jury at the Inquest could serve to reduce the risk of repetition of the circumstances giving rise to the death being required into, then Rule 42 of the Coroner’s Rules could and should be construed as allowing such a finding providing no individuals were named. The Secretary of State appealed to the House of Lords.

The decision

Three questions required an answer:-

(i) What, if anything, did the convention require of a properly conducted official investigation into a death possibly involving violation of Article 2?

(ii) Did the regime for holding Inquests established by the Coroner’s Act 1988 and Coroner’s Rule 1984 as hitherto followed meet the requirements of the convention?

(iii) If not, could the current regime governing the conduct of Inquests in England be revised so as to do so and if so how?

1. What did the convention require of a properly conducted official investigation?

To meet the procedural requirement of Article 2 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.

2. Did the regime for holding Inquests as hitherto understood and followed in England and Wales meet the requirement of the convention?

The Jury to an Inquest is required to set out who the deceased was and how when and where the deceased came by his death (Rule 36). Rule 42 provides that no verdict shall be framed in such a way as to determine any question of÷ liability on the part of a named person or civil liability. The orthodox analysis had interpreted the word “how” in Rule 36 as meaning “by what means” and not “in what broad circumstances”. In some cases the Article 2 obligation that the State had might be discharged by criminal proceedings. That would not always be the case – for example if a plea of guilty was accepted or if at Trial the Defendant’s mental state was in issue. The conclusion was inescapable that there were some cases where the current regime did not meet the convention requirements.

3. Could the current regime be revised so as to meet the requirements of the convention and if so how?

Only one change was needed, namely to interpret “how” in Rule 36 of the Rules and Section 11 of the Act in the broad sense which had been rejected in previous case law namely as meaning not simply “by what means” but “by what means and in what circumstances”. This would not require a change of approach in some cases where a traditional short form verdict would be satisfactory. It would be for the Coroner in the exercise of his discretion to decide how best in each particular case to elicit the Juror’s conclusion on the central issue or issues. It might be done by inviting a narrative form of verdict in which a Jury’s factual conclusions were briefly summarised or by inviting the Jury’s answer to factual questions put by the Coroner. It would be open to parties appearing or represented at the Inquest to make submissions to the Coroner on the means of eliciting the Jury’s factual conclusions and on any questions to put. However the choice had to remain that of the Coroner and his decision should not be disturbed by the Courts unless strong grounds were shown.

4. Rule 36 prohibited expressions of opinions on matters not comprised within Sub Rule 1 and must continue to be respected. However this did not preclude conclusions of fact as opposed to expressions of opinion. Rule 42 should still not be infringed in that there must be no finding of criminal liability on the part of a named person nor must the verdict appear to determine any question of civil liability. Acts or omissions may be recorded but expressions suggestive of civil liability (in particular “neglect” or “carelessness” and related expressions) should be avoided.

5. Under the 1984 Rules the Coroner had the power to make an appropriate report where he believed actions should be taken to prevent recurrence of fatalities similar to that in respect of which the Inquest was held. To comply with the convention is was not necessary that this part be exercised by the Jury, although the Coroner might well be influenced by the factual conclusions of the Jury. The procedural obligation under Article 2 will normally be most effectively discharged if a Coroner announced publicly, not only his intention to report any matter, but also the substance of the report neutrally expressed.

Appeal allowed in part; Court of Appeal’s declaration set aside.

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