R. (On the Application of Middleton) v. HM Coroner for Western Somerset: The Case of Public Neglect

R. (On the Application of Middleton) v. HM Coroner for Western Somerset

[2004] UKHL 10

11 March 2004

House of Lords

Brief Summary:

The applicant was the mother of a prisoner who committed suicide while in prison for murder.  The applicant sought to make public the note from the jury at the inquest that said that the prison had been negligent in failing to prevent the suicide.  The House of Lords held that the current regime was in violation of Article 2 of the ECHR and that the Coroners Act 1988 and Coroners Rules should be interpreted broadly to allow the coroner to report on all material issues that led to the victim's death, including prison neglect.

The Facts:

The applicant's son committed suicide in January 1999 whilst in prison for murder. He had been in custody since his conviction at the age of 14 for the murder of his 18-month-old niece, and was aged 30 when he died. He had a history of self-harm and was receiving medication for depression at the time of his death.

The verdict reached at a first coroner's inquest was quashed for want of sufficient enquiry and a second inquest was held in October 2002. At the end of the evidence the coroner ruled that the issue of “neglect” should not be left to the jury. However, he told the jury that, if they wished, they could give him a note regarding any specific areas of evidence, which he would consider in relation to his power under r.43 of the Coroners Rules 1984 (power to report to the relevant authority in order to prevent recurrence of similar fatalities). The jury returned a verdict that the deceased had taken his own life when the balance of his mind was disturbed, and stated in a note to the coroner that the Prison Service had failed in its duty of care for the deceased. The coroner declined the family's request to append the jury's note to the inquisition, but wrote to the Chief Inspector of Prisons drawing attention to the contents of the note.

In her application for judicial review, the applicant sought an order that the findings set out in the jury's note be publicly recorded, so that there should be a formal public determination of the Prison Service's responsibility for her son's death. The Judge declined the order on the basis that the coroner had acted unlawfully in suggesting production of the note, but declared that, due to the unavailability of a verdict of neglect, the inquest was inadequate to meet the procedural obligation in Art.2 ECHR. On appeal by the Secretary of  State, the Court of Appeal declared that where a coroner knew that an inquest was the way in which the state's Art.2 obligation was to be fulfilled, and a finding of neglect could reduce the risk of repetition of the circumstances leading to the death in question, it was necessary to construe r.42 of the Coroners Rules 1984 as allowing a finding of neglect, providing no individual was named therein. The Secretary of State appealed to their Lordships' House, seeking to have the Court of Appeal's declaration set aside.

The Holding:

According to the Law Lords, the European Court of Human Rights had interpreted Art.2 of the ECHR as imposing on member states substantive obligations not to take life without justification and also to establish a framework of laws, precautions, procedures and means of enforcement which would, to the greatest extent reasonably practicable, protect life. It had also interpreted Art.2 as imposing on member states a procedural obligation to initiate an effective public investigation by an independent official body into any death occurring in circumstances in which it appeared that one or other of the foregoing substantive obligations had been, or may have been, violated and it appeared that agents of the state were, or may have been, in some way implicated.

Further, in order to meet the procedural requirement of Art.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. This requirement applied, not only to cases involving the use of lethal force by agents of the state, but also to a broader category of cases such as cases of negligence. The Law Lords noted that a verdict of an inquest jury which did not express the jury's conclusion on a major issue canvassed in the evidence at the inquest (such as whether the prison had been negligent) could not satisfy or meet the expectations of the deceased's family or next-of-kin. Secondly, it would not promote the objects of the ECHR if domestic law were to distinguish between cases where an agent of the state may have used lethal force without justification and cases in which a defective system operated by the state may have failed to afford adequate protection to human life.

Accordingly, the current regime did not meet the requirements of Art. 2 in some cases, such as the present case.  The current regime could be revised so as to meet these requirements by interpreting “how” in s.11(5)(b)(ii) of the Coroners Act 1988 and r.36(1)(b) of the Coroners Rules 1984  as meaning not simply “by what means” but “by what means and in what circumstances.” In cases where this called for a change of approach it was for the coroner, in the exercise of his discretion, to decide how best, in the particular case, to elicit the jury's conclusion on the central issue or issues and his decision should not be disturbed by the courts unless strong grounds were shown.

Villain? 

The victim was a convicted murderer but his mother was merely trying to publicize the neglect in the prison system that led to his suicide.  A harder case than Sacker but still, not a villain.