R (AP and MP) v HMN Coroner for Worcestershire

JurisdictionEngland & Wales
JudgeMr Justice Hickinbottom
Judgment Date09 June 2011
Neutral Citation[2011] EWHC 1453 (Admin)
Docket NumberCase No: CO/9078/2010
CourtQueen's Bench Division (Administrative Court)
Date09 June 2011

The Queen on the application of

(1) Andrew Palmer
(2) Margaret Palmer
HM Coroner for the County of Worcestershire
(1) Worcestershire County Council
(2) The Chief Constable of West Mercia Police
Interested Parties

[2011] EWHC 1453 (Admin)


Mr Justice Hickinbottom

Case No: CO/9078/2010




Birmingham Civil Justice Centre,

Bull Street, Birmingham

Martin Westgate QC and Adam Straw (instructed by Deighton Guedella) for the Claimants.

The Defendant did not appear.

Jenni Richards QC (instructed by Weightmans LLP) for the First Interested Party.

Samantha Leek (instructed by the Force Soclicitor) for the Second Interested Party.

Hearing dates: 11–12 May 2011

Mr Justice Hickinbottom



On 20 May 2006, Adrian Palmer, a young man of 21 years of age with Asperger's Syndrome, died at the hands of Ben Murphy. Earlier that year, he had accused Murphy of raping him. Murphy was arrested, interviewed and bailed; but the Crown Prosecution Service ("the CPS") decided not to prosecute him. Murphy was upset with Adrian over the allegation, Adrian being the subject of various threats by Murphy or on his behalf.


Following Adrian's death, the Defendant coroner ("the Coroner") opened an inquest, but adjourned it pending the outcome of the criminal proceedings against Murphy, who was charged with Adrian's murder. Murphy was willing to plead guilty to manslaughter, but not to murder. Two trials proved inconclusive, the jury being unable to reach a verdict in either. At the end of the second trial, Murphy's plea of guilty to manslaughter was accepted, and he was sentenced to 4 years' imprisonment in December 2007.


The Claimants Mr & Mrs Palmer are Adrian's grandparents, with whom he lived. In April 2010, they wrote to the Coroner asking him to resume the inquest into Adrian's death, a request he refused on 26 May 2010. In these proceedings, with leave of Nicola Davies J, Mr & Mrs Palmer challenge that refusal.


The First Interested Party ("the Council") is Worcestershire County Council, the relevant social services authority. The Second Interested Party is the Chief Constable of West Mercia Police, who is liable for the acts and omissions of members of the West Mercia Police ("the Police Force").


Briefly, Mr & Mrs Palmer contend that there is an arguable case that the state in the form of the Interested Parties violated Adrian's rights under article 2 of the European Convention on Human Rights by failing to have in place adequate systems for the protection of vulnerable individuals such as Adrian, and in failing to take reasonable steps to safeguard him against a real and immediate risk to his life. In those circumstances, the state has an additional obligation under article 2 to ensure that an independent enhanced enquiry is conducted into his death. As no investigation sufficient to satisfy the obligations under article 2 has yet been conducted, the Coroner erred in refusing to resume his inquest, which is the only opportunity for the state's investigative obligation to be properly satisfied. It is submitted that the resumption of the inquest is therefore necessary to comply with article 2.


The Police Force and the Council deny that there was any arguable violation of Adrian's article 2 rights, and hence there is no obligation on the state to conduct an enhanced investigation into Adrian's death; but, in any event, they contend that, if there were such an obligation, then the investigations and procedures which have already been conducted would be sufficient to comply with it. In those circumstances, it is submitted on their behalf that the Coroner was lawfully entitled not to resume the inquest.


The Coroner attended the hearing before me, but, as usual in challenges to judicial decisions in this court, he did not play any part in the proceedings. The other parties were represented, and the assistance I obtained from Martin Westgate QC and Adam Straw for Mr & Mrs Palmer, Jenni Richards QC for the Council and Samantha Leek for the Police Force was considerable. I gratefully acknowledge it.

The Factual Background


Adrian was born on 19 November 1984. From the age of two years, he lived with his grandparents, Mr & Mrs Palmer, in Tenbury Wells, Worcestershire, whilst his mother lived in South Wales.


In his teens, Adrian was diagnosed as having Asperger's Syndrome and attention deficit hyperactivity disorder. Like many with Asperger's Syndrome, Adrian found social interaction difficult: he struggled to make and maintain relationships, and had difficulties understanding and reacting to social situations in a conventional or appropriate way. In their turn, those who cared for and otherwise knew Adrian found his behaviour challenging. In drink, his behaviour became even more unconventional. Some of his acquaintances appear to have deliberately plied him with drink to make him behave so.


Apparently because of concerns about the company he was keeping and the consequent risk to himself, in 1999, social services first became involved with Adrian at Mr & Mrs Palmer's request. In 2002, when he reached 18, he was allocated to the Council's Adult Services Learning Disability Service. In December 2004, an adult care assessment was completed, which recorded that Adrian had difficulty in interpreting motives and actions: he could antagonise people, could place himself in risky situations and could easily be led, which put him at some risk in the community. However, he was assessed as a low to moderate priority.


From 2001 to July 2005, he was at Ruskin Mill College, a residential educational establishment for young people with developmental needs. When he left, the Council did not consider that he needed 24 hour per day care, and he lived with Mr & Mrs Palmer who pressed the Council to give them more support.


On 23 March 2005, Adrian telephoned the police about a pub opening out of hours, and told them that someone had threatened to kill him that evening. There is no suggestion that the person who threatened him was Murphy. However, the police would not attend, so Adrian went to the fire station for help. It was closed, but he broke in and took a fire engine by driving it through the closed shutter doors and out onto the open road. He drove for about 6 miles, before driving the fire engine into a field and being apprehended. The damage was valued at over £10,000. Adrian was prosecuted for aggravated vehicle taking, but was found unfit to stand trial. He was however tried under the provisions of the Criminal Procedure (Insanity) Act 1964, and found to have done the act of taking the fire engine; and, on 10 February 2006, under section 5 of that Act, he was made the subject of a 2-year supervision order with the Council being the supervising authority.


However, in the meantime, there had been another development, important for the purposes of this claim. On the evening of 6 January 2006, Adrian went out with several friends. As he was walking home with one of them (Ms Cher Marsden), he told her that Murphy had raped him. She said that they should go and see her mother (Mrs Antoinette Williams), which they did. He told her too that Murphy had raped him. She advised him to ring the police, which he did, at 3am on 7 January.


According to the police record of the report Adrian appeared to be "very intoxicated", and said that he was getting revenge on Murphy for raping him four years ago. He said he did not want to kill Murphy, but that he "needed" to do so. He said he did not want to be arrested: he wanted to be taken home. Two officers attended, and did take him back to his grandparents' house, where arrangements appear to have been made for a vulnerable witness interview in relation to his claim that he had been raped. The officers left; but, within half an hour, the police received another call, this time from Mr Palmer, who said that Adrian was wrecking the house, and Mr & Mrs Palmer could not cope. The police officers re-attended and arrested Adrian. At the police station, Adrian said that the reason he had "kicked off" was because Murphy had been blackmailing him for sex.


Adrian was released the following morning, and, when he got home, in the presence of his grandmother, he gave the police an initial account of what Murphy had done to him. Mr & Mrs Palmer then took him to South Wales, where he stayed with his mother, returning to Tenbury on 12 January, to take part in a visually recorded interview. In view of his Asperger's Syndrome, he was interviewed in the presence of an appropriate adult, namely Mrs Williams.


That evening, Mr Palmer reported Adrian was missing. He was found by police and returned home, within the hour. However, the officer who found him logged that rumours of the rape allegation were circulating, apparently having been spread by Mrs Williams. Adrian then returned to stay in South Wales with his mother and Ms Marsden, although apparently returning to Tenbury for some weekends.


Murphy was arrested, interviewed and bailed on 26 January, and his home was searched the same day.


On 28 January, Adrian's mother contacted the police to say that Adrian and Ms Marsden had been staying with her in Wales. However, Adrian had attempted to kiss Cher, with the result that she had left and returned to Tenbury. They had apparently fallen out over this. She had sent a text to Adrian saying that she did not want anything more to do with him, and she would support Murphy and not Adrian. It said: "I'm in the Vaults [public house in...

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