R. (on the application of Sacker) v HM Coroner for West Yorkshire11 March 2004
 H.R.L.R. 30
House of Lords
 H.R.L.R. 30
House of Lords
This case concerns Coroners Rules 1984 r.36(1)(b) and whether there is right to life-positive obligation on the State to take effective operational measures to safeguard life. In an inquest following the suicide of prisoner where the correct prison procedures were not followed, the House of Lords held that the coroner's refusal to allow jury to add rider to verdict stating “contributed to by neglect” was incompatible with Art.2 of the European Convention on Human Rights (Right to Life). Under Article 3 of the Human Rights Act, the House of Lords held that the Coroners Rules requirement that the inquest determine "how" the prisoner died should include “in what circumstances” as well as “by what means.”
The respondent's daughter (“C”) had committed suicide while in prison. C had been charged with an offence of dishonesty and remanded in custody, where she had been placed on an opiate withdrawal programme. At a subsequent court hearing, upon being refused bail, C had reacted aggressively. In view of her distressed state, a “self-harm at risk” form had been opened by the court custody officer. On the following day, the Governor, who had not been made aware of the “self-harm at risk” form, found C guilty of a disciplinary offence related to her conduct at court and ordered a penalty that included loss of association. The locum medical officer who examined C concluded that she was not suicidal. He was not familiar with the procedure associated with the form, referred C back from the prison health centre to the residential wing, and did not complete the “discharge report” panel of the form. C hanged herself from a ligature in her cell.
A prison service report on C's death contained numerous criticisms of the systems that were in operation on the night of C's death. At the inquest, the appellant coroner, following the Court of Appeal's guidance in R. v Coroner for North Humberside and Scunthorpe, Ex p. Jamieson  Q.B. 1 , refused to give the jury the opportunity to include in their verdict a finding that the death had been “contributed to by neglect”. Section 11(5)(b)(ii) of the Coroners Act 1988 and r.36(1)(b) of the Coroners Rules 1984 provided that an inquisition should set out how the deceased came to her death, which in Ex p. Jamieson had been held to mean “by what means” and not “in what circumstances”. The respondent sought judicial review of the coroner's refusal. The Court of Appeal quashed the inquisition and ordered a new inquest. The coroner appealed to the House of Lords.
The House of Lords upheld the order for a new inquest. According to the court, the public investigation of deaths in prison had long been a requirement under domestic law, but that requirement had been given added importance by the HRA. Article 2 of the European Convention on Human Rights required that deaths in custody be investigated, and a coroner's inquest was the usual means by which that obligation was complied with in the United Kingdom. Further, the purpose of the investigation was to open up the circumstances of the death to public scrutiny. According to the court, a rigorous examination in public of the operation at every level of the systems and procedures which had been designed to prevent self-harm and to save lives was required.
The key issue was the word “how” in s.11(5)(b)(ii) of the Coroners Act 1988 and r.36(1)(b) of the Coroners Rules 1984, and whether this word could be interpreted to mean not simply “by what means” but rather “by what means and in what circumstances”. Section 3 HRA 1998 required that the word be given the broader meaning. Because the original inquest had limited the investigation to "by what means" the prisoner died, it had not been permitted to identify the cause or causes of C's suicide, the steps that could have been taken but were not taken to prevent it, and the precautions that ought in future to be taken to avoid or reduce the risk to other prisoners. Consequently, the inquest had been deprived of its ability to address the positive obligation that Art.2 placed on the State to take effective operational measures to safeguard life.
The claimant is the mother of a woman who committed suicide while in prison for a minor drug offense. The prisoner is arguably not a villain and her mother is definitely not a villain.