Acting to stop harm: the FCA and Appointed Representatives
In the reported case of R (Silvera) v HM Senior Coroner for Oxfordshire  EWHC 2499 (Admin), the Divisional Court looked at the investigative duties placed on the state by Article 2 of the European Convention on Human Rights and the importance of the coronial process in ensuring that those duties have been met. Specifically, the Court looked at the power of a coroner to resume a suspended investigation following other investigations and criminal proceedings. The Chief Coroner, before whom these judicial review proceedings were heard, found that the decision of the Senior Coroner for Oxfordshire not to resume an inquest following a criminal conviction for manslaughter was in breach of Article 2.
The judgment of the court was a reminder of the burden of the investigative duties placed on coroners by the European Convention on Human Rights even in cases where a death has been the subject of other investigations and proceedings. Although this case turned on its facts, it should give coroners good reason to consider more carefully whether to resume inquests after criminal proceedings and other investigations.
The Claimant’s mother, Ms Baker, died on or around 16 August 2012 in violent or unnatural circumstances and shortly after the Senior Coroner for Oxfordshire opened an inquest. In July 2013, the Claimant’s sister (“K”) pleaded guilty to the manslaughter of her mother on the basis of diminished responsibility and was detained in a secure mental health hospital. In July 2014 the Senior Coroner decided not to resume the inquest. He confirmed this decision in a letter to the Claimant’s solicitors in February 2016.
Both Ms Baker and K had a history of mental illness. They had been living together and were under the care of a community psychiatric nurse. In July 2012 K had been admitted to hospital under section 2 of the Mental Health Act 1983. She was transferred to a Psychiatric Intensive Care Unit but was then discharged by a consultant doctor, who had no prior knowledge of K, and moved on to an open ward. K absconded on 11 August 2012. Ward staff warned police that she was unwell and psychotic, that she had assaulted a member of staff, and that being out in public meant that she “might do something”. The police said it was the ward’s responsibility to locate K although they attended Ms Baker’s address for a welfare check. K told the police she would return to the ward but failed to do so. Ward staff warned that they were concerned about Ms Baker and also raised concerns about the welfare of their own staff if they tried to retrieve K. On 16 August 2012 Ms Baker was found dead in her property and K, who was still in the property, was arrested.
In addition to the criminal proceedings, there were two other investigations into the circumstances that led to the death of Ms Baker:
In his February 2016 letter confirming his decision not to re-open the inquest into Ms Baker’s death, the Senior Coroner stated that “a suspended investigation may only be resumed if the Coroner thinks that there is a sufficient reason to do so”. He stressed the discretionary nature of the coroner’s decision and stated that the test was “whether the facts of the death have been adequately aired”. He explained that he did not believe Article 2 applied and that, even if it did, the requirements of Article 2 had been satisfied by the Crown Court proceedings combined with the above two mentioned investigations.
In his judgment, the Chief Coroner found that the Senior Coroner had applied the wrong test. The test is found at Para. 8 of Schedule 1 to the Coroner and Justice Act 2009 where it states: “An investigation that is suspended under paragraph 2 may not be resumed unless, but must be resumed if, the senior coroner thinks that there is sufficient reason for resuming it”. The Senior Coroner therefore was required to consider whether there was a sufficient reason for resuming the inquest and there was no requirement for there to be exceptional circumstances.
The Chief Coroner confirmed that Article 2 was engaged and that the investigations to date had not discharged the duty of investigation which was therefore triggered. It was relevant that the Crown Court had accepted a guilty plea so there had been no trial and the two investigations which had taken place had not been of a public nature and there had not been proper involvement of the family.
Although this case turned on the facts, it is a useful reminder of the importance of an inquest in ensuring the State has met its investigative duties in a situation where Article 2 is engaged. The public nature of an inquest and the involvement of family members are features of an inquest which enable this duty to be met even where the death has been investigated, arguably thoroughly so, in other ways.
 Per Simon Brown LJ at pg. 155e R. v. Inner West London Coroner, ex parte Dallagio and another  4 All ER 139
Inquest proceedings, like other legal proceedings in the UK, have been significantly affected by social distancing restrictions and advice arising from the COVID-19 crisis. This blog looks briefly at the impact of the Coronavirus Act 2020 on proceedings, and examines the Chief Coroner’s guidance notes to coroners working during the crisis.
Inquests are always very sad affairs, and when the court is considering a suicide, it is particularly difficult for the loved ones of the person who has died.
At the end of the inquest in 2014 into the death of Ella Kissi-Debrah, the coroner concluded that this nine year old girl suffered an asthma attack, followed by a seizure, and died after unsuccessful resuscitation. This is one possible answer to the question of how Ella died. However, there is clearly a bigger question which needs to be answered.
As we discussed in our recent blog, some inquests will automatically be designated ‘Article 2 inquests’ if the deceased died whilst under the control of the state. Other inquests will only become Article 2 inquests if there is evidence of systemic failures of processes and systems to protect life. Therefore a case of ordinary medical negligence would not trigger Article 2, as confirmed in Parkinson  4 W.L.R 106.
In June 2018 the government announced that some bereaved families should find it easier to access legal aid funding for representation at inquests. The updated guidance issued by the Lord Chancellor allows caseworkers to waive the financial means test “for cases where the state has a procedural obligation to hold an inquest under Article 2”.
In February 2019 in its Final Report on the Review of Legal Aid for Inquests, the Ministry of Justice confirmed that it would not be introducing automatic public funding for families at inquests where the state is legally represented. This is hugely disappointing news for families, such as the family of PC Palmer, who have experienced the reality of an inquest where the state has the benefit of a highly experienced and well-resourced legal team while they are left to try and find lawyers prepared to represent them for free.
The husband and children of the school teacher, Ann Maguire, who was murdered by a pupil, William Cornick, in her classroom in April 2014 have been unsuccessful in their attempt to appeal against the decision of the High Court to dismiss their claim for judicial review of a decision of the Assistant District Coroner for West Yorkshire.
Today, the Health Secretary announced “a new maternity strategy to reduce the number of stillbirths. This strategy centres on the investigation of still birth deaths by the new Healthcare Safety Investigations Branch but it also included a planned change in the law to allow coroners to investigate full term still birth deaths. Currently there is no requirement for a doctor to refer a still birth death to the local coroner.
In the recently reported case of R (Silvera) v HM Senior Coroner for Oxfordshire  EWHC 2499 (Admin), the Divisional Court looked at the investigative duties placed on the state by Article 2 of the European Convention on Human Rights and the importance of the coronial process in ensuring that those duties have been met.
The recent decision of Mr Justice Holroyde in R oao Donald Maguire and ors v The Assistant Coroner for West Yorkshire (Eastern Area)  EWHC 2039 provides a salutary reminder of just how difficult it is successfully to judicially review the ‘case management’ decisions of a coroner – in this case a decision as to which witnesses to call at an inquest – and of the costs risks of bringing such a challenge.
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