Law Lords rule the inquest juries should explain their verdicts

The House of Lords held that a jury’s remit to decide the question of “how” a prisoner died under the Coroners Act 1988 should be extended to “by what means and in what circumstances” if the jurors wished to express concern about the circumstances of a death, in what is believed to be the first case about the role of the Coroners’ Court to come before the House of Lords in 100 years.

The rulings, R v. HM Coroner for the Western District of Somerset and other (Appellant) ex parte Middleton and R v. HM Coroner for the County of West Yorkshire ex parte Sacker, have been welcomed by the campaigning group Inquest as “a major breakthrough”. One case concerned the death of 31 year old Colin Middleton in January 1999 at Bristol Prison. A jury and the coroner both felt that there were “significant deficiencies” in the care given by the Prison Service, who was not placed on suicide watch despite signs of possible self-harm.

During the inquest the Coroner heard details that prompted him to announce that he would be writing to HM Chief Inspector of Prisons over his concerns. He was also passed a note by the jury which raised a number of their concerns about the practices adopted by the prison authorities. The family’s lawyers later asked for the jury’s note to be incorporated into the verdict, which was otherwise to be recorded simply as the taking of his own life while the balance of his mind was disturbed.

This prompted the dispute between the family and the Home Office over the scope of inquest verdicts to record findings of fault and in particular failures in the system referred to as “system neglect”. The family questioned whether the current inquest system was compatible with the Human Rights Act, in particular, Article 2 which obliges the state to safeguard the lives of those within its control. The duty to safeguard life has been interpreted in European Court decisions, as implying a duty to investigate where death has occurred at the hands of the state.

“In England and Wales an inquest is the means by which the state ordinarily discharges that obligation, save where a criminal prosecution intervenes or a public enquiry is ordered into a major accident …,” the Law Lords ruled. “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.”

They noted that the statistics on deaths in custody, “grim though they are”, did not “point towards any dereliction of duty on the part of the authorities”. “But they do highlight the need for an investigative regime which will not only expose any past violation of the state’s substantive obligations already referred to but also, within the bounds of what is practicable, promote measures to prevent or minimise the risk of future violations,” they said.

According to the campaigning group Inquest, the significance of the rulings is that they will require an inquest to return verdicts which properly reflect whether a person takes their own life in part because the dangers of their doing so were not recognised by the prison authorities and whether appropriate precautions could have been taken to prevent the death. “[We hope] that this will result in a more meaningful inquest system where the Prison Service is held accountable for its actions,” co-director Deborah Coles commented. “No family should have to endure a death that does not result in thorough scrutiny of individual and systemic failings.”

“The unanswered question is how broad is the application of this case,” said Richard Eaton, a solicitor-advocate from Clarke Willmott solicitors, who represented Michael Rose, the coroner for West Somerset. “The new interpretation of what the question ‘how’ means that it certainly covers prison suicides, and investigations at the hands of the state. But the Lords have said that the scope for juries to give a more detailed answer will be less in other cases.”