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You are here: BAILII >> Databases >> United Kingdom House of Lords Decisions >> Middleton, R (on the application of) v Coroner for the Western District of Somerset [2004] UKHL 10 (11 March 2004) URL: http://www.bailii.org/uk/cases/UKHL/2004/10.html Cite as: (2004) 168 JP 329, [2004] Lloyd's Rep Med 288, [2004] UKHL 10, [2004] Lloyds Rep Med 288, (2004) 79 BMLR 51, 17 BHRC 49, (2004) 168 JPN 479, [2004] 2 AC 182, [2004] UKHRR 501, [2004] 2 WLR 800, [2004] 2 All ER 465 |
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Judgments - Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)
HOUSE OF LORDS
SESSION 2003-04
19th REPORT
[2004] UKHL 10
on appeal from: [2002] EWCA Civ 390
APPELLATE COMMITTEE
Regina v. Her Majesty's Coroner for the Western District of
Somerset (Respondent) and other (Appellant) ex parte
Middleton (FC) (Respondent)
REPORT
Ordered to be printed 11 March 2004
LONDON
(HL Paper 51)
19th REPORT
from the Appellate Committee
11 MARCH 2004
Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)
ORDERED TO REPORT
The Committee (Lord Bingham of Cornhill, Lord Hope of Craighead, Lord Walker of Gestingthorpe, Baroness Hale of Richmond and Lord Carswell) have met and considered the cause Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent). We have heard counsel on behalf of the appellant and both respondents.
(1)What, if anything, does the Convention require (by way of verdict, judgment, findings or recommendations) of a properly conducted official investigation into a death involving, or possibly involving, a violation of article 2?
(2)Does the regime for holding inquests established by the Coroners Act 1988 and the Coroners Rules 1984 (SI 1984/552), as hitherto understood and followed in England and Wales, meet those requirements of the Convention?
(3)If not, can the current regime governing the conduct of inquests in England and Wales be revised so as to do so, and if so how?
"must be guided by the fact that the object and purpose of the Convention as an instrument for the protection of individual human beings requires that its provisions be interpreted and applied so as to make its safeguards practical and effective."
Thus if an official investigation is to meet the state's procedural obligation under article 2 the prescribed procedure must work in practice and must fulfil the purpose for which the investigation is established.
"that the inquest, which did not permit the determination of issues of liability, did not furnish the applicant with the possibility of establishing the responsibility of the prison authorities or obtaining damages."
In paragraph 122 the Court, still with reference to this complaint, ruled:
"Given the fundamental importance of the right to the protection of life, Article 13 requires, in addition to the payment of compensation where appropriate, a thorough and effective investigation capable of leading to the identification and punishment of those responsible for the deprivation of life . . ."
On the facts, the Court held (paragraph 131) that a civil action in damages would not have afforded the applicant an effective remedy which would have established where responsibility lay for the death of the deceased.
"105The obligation to protect the right to life under Article 2 of the Convention, read in conjunction with the State's general duty under Article 1 of the Convention to 'secure to everyone within [its] jurisdiction the rights and freedoms defined in [the] Convention', also requires by implication that there should be some form of effective official investigation when individuals have been killed as a result of the use of force. The essential purpose of such investigation is to secure the effective implementation of the domestic laws which protect the right to life and, in those cases involving State agents or bodies, to ensure their accountability for deaths occurring under their responsibility. What form of investigation will achieve those purposes may vary in different circumstances. However, whatever mode is employed, the authorities must act of their own motion, once the matter has come to their attention. They cannot leave it to the initiative of the next-of-kin either to lodge a formal complaint or to take responsibility for the conduct of any investigative procedures . . .
107The investigation must also be effective in the sense that it is capable of leading to a determination of whether the force used in such cases was or was not justified in the circumstances and to the identification and punishment of those responsible. This is not an obligation of result, but of means. The authorities must have taken the reasonable steps available to them to secure the evidence concerning the incident, including inter alia eye witness testimony, forensic evidence and, where appropriate, an autopsy which provides a complete and accurate record of injury and an objective analysis of clinical findings, including the cause of death. Any deficiency in the investigation which undermines its ability to establish the cause of death or the person or persons responsible will risk falling foul of this standard."
There was argument whether the inquest, which had been opened but not concluded, would satisfy the state's investigative obligation, but the Court concluded that, on the facts of this case, it would not:
"128It is also alleged that the inquest in this case is restricted in the scope of its examination. According to the case law of the national courts, the procedure is a fact-finding exercise and not a method of apportioning guilt. The Coroner is required to confine his investigation to the matters directly causative of the death and not to extend his inquiry into the broader circumstances. This was the standard applicable in the McCann inquest also and did not prevent examination of those aspects of the planning and conduct of the operation relevant to the killings of the three IRA suspects. The Court is not persuaded therefore that the approach taken by the domestic courts necessarily contradicts the requirements of Art. 2. The domestic courts accept that an essential purpose of the inquest is to allay rumours and suspicions of how a death came about. The Court agrees that a detailed investigation into policy issues or alleged conspiracies may not be justifiable or necessary. Whether an inquest fails to address necessary factual issues will depend on the particular circumstances of the case. It has not been shown in the present application that the scope of the inquest as conducted so far has prevented any particular matters relevant to the death being examined.
129Nonetheless, unlike the McCann inquest, the jury's verdict in this case may only give the identity of the deceased and the date, place and cause of death. In England and Wales, as in Gibraltar, the jury is able to reach a number of verdicts, including 'unlawful death'. As already noted, where an inquest jury gives such a verdict in England and Wales, the DPP is required to reconsider any decision not to prosecute and to give reasons which are amenable to challenge in the courts. In this case, the only relevance the inquest may have to a possible prosecution is that the Coroner may send a written report to the DPP if he considers that a criminal offence may have been committed. It is not apparent however that the DPP is required to take any decision in response to this notification or to provide detailed reasons for not taking any further action. In this case it appears that the DPP did reconsider his decision not to prosecute when the Coroner referred to him information about a new eye witness who had come forward. The DPP maintained his decision however and gave no explanation of his conclusion that there remained insufficient evidence to justify a prosecution.
130Notwithstanding the useful fact-finding function that an inquest may provide in some cases, the Court considers that in this case it could play no effective role in the identification or prosecution of any criminal offences which may have occurred and, in that respect, falls short of the requirements of Art. 2."
The Court held (paragraph 142) that the Northern Irish inquest procedure fell short of what article 2 required because (among other shortcomings) it
"did not allow any verdict or findings which could play an effective role in securing a prosecution in respect of any criminal offence which may have been disclosed."
"… that those who have lost their relative may at least have the satisfaction of knowing that lessons learned from his death may save the lives of others."
"(a) has died a violent or an unnatural death;
(b)has died a sudden death of which the cause is unknown; or
(c)has died in prison or in such a place or in such circumstances as to require an inquest under any other Act."
If there is reason to suspect that the death occurred in prison or in police custody or resulted from an injury caused by a police officer in the purported execution of his duty, the inquest must be held with a jury (section 8(3)), and the independence of jurors dealing with prison deaths is specifically protected (section 8(6)). The requirement to summon a jury in such cases recognises the substantive and procedural obligations of the state which are now derived from article 2 as well as from domestic law. If a coroner fails to hold an inquest when he should, he may be ordered to do so, and if a coroner misconducts an inquest, another inquest may be ordered (section 13).
"(i)who the deceased was; and
(ii)how, when and where the deceased came by his death."
"At a coroner's inquest into the death of a person who came by his death by murder, manslaughter or infanticide, the purpose of the proceedings shall not include the finding of any person guilty of the murder, manslaughter or infanticide; and accordingly a coroner's inquisition shall in no case charge a person with any of those offences."
Thus the inquest jury may no longer perform its former role as a grand jury. Section 16 of the Act (and rules 27 and 28 of the Rules) make provision for the adjourning of an inquest when criminal proceedings are or may be pending on certain specified charges or in certain specified circumstances (but not solely because any criminal proceedings arising out of the death of the deceased have been instituted: rule 32 of the Rules). After the conclusion of criminal proceedings the coroner may resume the adjourned inquest "if in his opinion there is sufficient cause to do so" (section 16(3)). Section 17A makes provision for the adjourning of an inquest when a public inquiry into a death is to be conducted or chaired by a judge. A coroner may only resume an inquest so adjourned "if in his opinion there is exceptional reason for doing so", and then subject to conditions (section 17A (4)).
"A coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the inquest is being held may announce at the inquest that he is reporting the matter in writing to the person or authority who may have power to take such action and he may report the matter accordingly."
Attention should be drawn to two important rules. The first of these, rule 36, provides:
"(1)The proceedings and evidence at an inquest shall be directed solely to ascertaining the following matters, namely -
(a)who the deceased was;
(b)how, when and where the deceased came by his death;
(c)the particulars for the time being required by the Registration Acts to be registered concerning the death.
(2)Neither the coroner nor the jury shall express any opinion on any other matters."
The second, rule 42, provides:
"No verdict shall be framed in such a way as to appear to determine any question of -
(a)criminal liability on the part of a named person, or
(b)civil liability."
The present case.
"(a)expressed concern that a form F2052SH had been closed by two officers who had no prior knowledge of Mr Middleton; and
(b)expressed their belief that a letter of 11 January 1999 written by him contained sufficient information to warrant an F2052SH being opened."
In exercise of his power under rule 43, the coroner wrote a full letter to the Chief Inspector of Prisons, drawing attention to the jury's point (a) and to the jury's noting of "a failure in the prison's responsibilities towards Middleton and a total lack of communication between all grades of prison staff". The coroner pointed 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.
"However, where there has been neglect on the part of the State, and that neglect was a substantial contributory cause of the death, my view is that a formal and public finding of neglect on the part of the State is in general necessary in order to satisfy those requirements [of article 2]."
He therefore concluded (paragraph 56) that an inquest would not necessarily satisfy the procedural requirements of article 2 in a case such as the present. But the judge declined to order that the jury's note be incorporated in the inquisition, for a series of reasons but most importantly because he considered that the coroner had acted unlawfully in suggesting production of the note. The judge recorded (paragraph 60) that in the view of the jury and the coroner there had been significant deficiencies in the Prison Service's care of the deceased. 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 at the inquest into the death of [the deceased] . . . that inquest was inadequate to meet [the] procedural obligation in Article 2 of the European Convention . . ."
The Secretary of State appealed to the Court of Appeal which delivered its reserved judgment on 27 March 2002: [2002] EWCA Civ 390, [2003] QB 581. It was found to be necessary, to comply with article 2, that a verdict of neglect be available, but the Court of Appeal distinguished between individual and systemic neglect:
"87 A verdict of neglect can perform different functions. In particular, in the present context, it can identify a failure in the system adopted by the Prison Service to reduce the incidence of suicide by inmates. Alternatively it may do no more than identify a failure of an individual prison officer to perform his duties properly. We offer two illustrations, which demonstrate the distinction we have in mind. On the one hand, the system adopted by a prison may be unsatisfactory in that it allows a prisoner who is a known suicide risk to occupy a cell by himself or does not require that prisoner to be kept under observation. On the other hand, the system may be perfectly satisfactory but the prison officer responsible for keeping observation may fall asleep on duty.
88 For the purpose of vindicating the right protected by article 2 it is more important to identify defects in the system than individual acts of negligence. The identification of defects in the system can result in it being changed so that suicides in the future are avoided. A finding of individual negligence is unlikely to lead to that result. If the facts have been investigated at the inquest the evidence given for this purpose should usually enable the relatives to initiate civil proceedings against those responsible without the verdict identifying individuals by name. The shortcomings of civil proceedings in meeting the requirements of article 2 do not in general prevent actions in the domestic courts for damages from providing an effective remedy in cases of alleged unlawful conduct or negligence by public authorities.
89 In contrast with the position where there is individual negligence, not to allow a jury to return a verdict of neglect in relation to a defect in the system could detract substantially from the salutary effect of the verdict. A finding of neglect can bring home to the relevant authority the need for action to be taken to change the system, and thus contribute to the avoidance of suicides in the future. The inability to bring in a verdict of neglect (without identifying any individual as being involved) in our judgment significantly detracts, in some cases, from the capacity of the investigation to meet the obligations arising under article 2."
Later, the court continued:
". . . In a situation where a coroner knows that it is the inquest which is in practice the way the state is fulfilling the adjectival obligation under article 2, it is for the coroner to construe the Rules in the manner required by section 6(2)(b) [of the Human Rights Act 1998]. Rule 42 can and should, contrary to R v Coroner for North Humberside and Scunthorpe, Ex p Jamieson [1995] QB 1, when necessary be construed (in relation to both criminal and civil proceedings) only as preventing an individual being named, with the result that a finding of system neglect of the type we have indicated will not contravene that rule. If the coroner is acting in accordance with the rule for this purpose he will not be offending in this respect section 6(1).
92 For a coroner to take into account today the effect of the Human Rights Act 1998 on the interpretation of the Rules is not to overrule Jamieson's case by the back door. In general the decision continues to apply to inquests, but when it is necessary so as to vindicate article 2 to give in effect a verdict of neglect, it is permissible to do so. The requirements are in fact specific to the particular inquest being conducted and will only apply where in the judgment of the coroner a finding of the jury on neglect could serve to reduce the risk of repetition of the circumstances giving rise to the death being inquired into at the inquest. Subject to the coroner, in the appropriate cases, directing the jury when they can return what would in effect be a rider identifying the nature of the neglect they have found, the rules will continue to apply as at present. The proceedings should not be allowed to become adversarial. We appreciate there is no provision for such a rider in the model inquisition but this technicality should not be allowed to interfere with the need to comply with section 6 of the Human Rights Act 1998."
The Court of Appeal set aside the judge's declaration and instead declared:
"In a case where
(a)a coroner knows that it is the inquest which is in practice the way the State is to fulfil the adjectival obligation under Article 2 of the European Convention on Human Rights, and
(b)a 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 inquired into,
rule 42 of the Coroners Rules 1984 can and should be construed as allowing such a finding, providing no individual is named therein."
APPENDIX I ORDERS OF REFERENCE, ETC.
WEDNESDAY 20 JUNE 2001
Appeal Committees—Two Appeal Committees were appointed pursuant to Standing Order.
Appellate Committees—Two Appellate Committees were appointed pursuant to Standing Order.
____________________
THURSDAY 4 JULY 2002
Regina v. H M Coroner for the Western District of Somerset (Respondent) and another (Petitioner) ex parte Middleton (Respondent)—The petition of the Secretary of State for the Home Department praying for leave to appeal was presented and referred to an Appeal Committee (lodged 25th April).
____________________
TUESDAY 24 SEPTEMBER 2002
Regina v. H M Coroner for the Western District of Somerset (Respondent) and another (Petitioner) ex parte Middleton (FC) (Respondent)—The certificate of public funding of Jean Middleton was lodged.
____________________
WEDNESDAY 13 NOVEMBER 2002
Appeal Committees—Two Appeal Committees were appointed pursuant to Standing Order.
Appellate Committees—Two Appellate Committees were appointed pursuant to Standing Order.
____________________
THURSDAY 14 NOVEMBER 2002
Regina v. H M Coroner for the Western District of Somerset (Respondent) and another (Petitioner) ex parte Middleton (FC) (Respondent)—That leave to appeal be given, and that the petition of appeal be lodged by 28th November.
_________
MONDAY 2 DECEMBER 2002
Regina v. H M Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent) (England)—The appeal of the Secretary of State for the Home Department was presented and it was ordered that in accordance with Standing Order VI the statement and appendix thereto be lodged on or before 13th January next (lodged 28th November).
___________
MONDAY 13 JANUARY 2003
Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)—The petition of the appellant praying that the time for lodging the statement and appendix and setting down the cause for hearing might be extended to 10th February next (the agents for the respondent consenting thereto) was presented; and it was ordered as prayed.
_____________
MONDAY 10 FEBRUARY 2003
Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)—The petition of the appellant praying that the time for lodging the statement and appendix and setting down the cause for hearing might be extended to 10th March next (the agents for the respondent consenting thereto) was presented; and it was ordered as prayed.
_______
MONDAY 10 MARCH 2003
Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)—The petition of the appellant praying that the time for lodging the statement and appendix and setting down the cause for hearing might be extended to 31st March next (the agents for the respondent consenting thereto) was presented; and it was ordered as prayed.
___________
TUESDAY 1 APRIL 2003
Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)—The appeal was set down for hearing and referred to an Appellate Committee.
_________
FRIDAY 18 JULY 2003
Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)—The petition of Inquest and its associated charitable trust praying for leave to intervene in the said appeal was presented and referred to an Appeal Committee.
____________________
THURSDAY 31 JULY 2003
Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)—That the petition of Inquest and its associated charitable trust that they might be heard or otherwise intervene in the said appeal be allowed to the extent that they may lodge written submissions only.
____________________
THURSDAY 2 OCTOBER 2003
Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)—The petition of the Northern Ireland Human Rights Commission praying for leave to intervene in the said appeal was presented and referred to an Appeal Committee.
____________________
THURSDAY 9 OCTOBER 2003
Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)—That the petition of the Northern Ireland Human Rights Commission that they might be heard or otherwise intervene in the said appeal be allowed to the extent that they may lodge written submissions only.
____________________
WEDNESDAY 26 NOVEMBER 2003
Appeal Committees—Two Appeal Committees were appointed pursuant to Standing Order.
Appellate Committees—Two Appellate Committees were appointed pursuant to Standing Order.
____________________
MONDAY 26 JANUARY 2004
Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)—The petition of the Coroners' Society of England and Wales praying for leave to intervene in the said appeal was presented and referred to an Appeal Committee.
____
WEDNESDAY 28 JANUARY 2004
Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)—That the petition of the Coroners' Society of England and Wales that they might be heard or otherwise intervene in the said appeal be allowed to the extent that they may lodge written submissions only.
__________
APPENDIX II MINUTES OF PROCEEDINGS
MONDAY 2 FEBRUARY 2004
Present:
L. Bingham of Cornhill
B. Hale of Richmond
L. Lord Hope of Craighead
L. Carswell
L. Walker of Gestinghorpe
The Lord Bingham of Cornhill in the Chair.
The Orders of Reference are read.
The Committee deliberate.
Counsel and Parties are called in.
Mr J. Crow and Mr R. Singh QC appear for the appellant.
Mr B. Emmerson QC, Mr P. Weatherby and Mr D. Friedman appear for the respondent Middleton.
Mr H. Mercer and Mr R. Eaton appear for the respondent Her Majesty's Coroner for the Western District of Somerset.
Mr Crow heard.
Mr Mercer heard.
In part heard and adjourned until tomorrow.
TUESDAY 3 FEBRUARY 2004
Present:
L. Bingham of Cornhill
B. Hale of Richmond
L. Lord Hope of Craighead
L. Carswell
L. Walker of Gestinghorpe
The Lord Bingham of Cornhill in the Chair.
The Order of Adjournment is read.
The proceedings of yesterday are read.
The Committee deliberate.
Counsel and Parties are again called in.
Mr Mercer further heard.
Mr Emmerson heard.
Further heard and adjourned until tomorrow.
WEDNESDAY 4 FEBRUARY 2004
Present:
L. Bingham of Cornhill
B. Hale of Richmond
L. Lord Hope of Craighead
L. Carswell
L. Walker of Gestinghorpe
The Lord Bingham of Cornhill in the Chair.
The Order of Adjournment is read.
The proceedings of yesterday are read.
The Committee deliberate.
Counsel and Parties are again called in.
Mr Emmerson further heard.
Mr Crow heard in reply.
Further and fully heard.
Bar cleared; and the Committee deliberate.
A draft Report is laid before the Committee by the Lord Bingham of Cornhill.
The Report is considered and agreed to unanimously.
Ordered, That the Lord Bingham of Cornhill do make the Report to the House.
Ordered, That the Committee be adjourned.
