R (Jean Middleton) v HM Coroner for Western Somersetshire and Secretary of State for the Home Department
| Jurisdiction | England & Wales |
| Judgment Date | 14 December 2001 |
| Neutral Citation | [2001] EWHC 1043 (Admin) |
| Date | 14 December 2001 |
| Court | Queen's Bench Division (Administrative Court) |
[2001] EWHC Admin 1043
Court and Reference:Administrative Court ; CO/563/2001
Stanley Burnton J
Appearances:B Emmerson QC and P Weatherby (instructed by Howells) for M; R Wilkinson (instructed by Clarke, Willmott & Clarke) for the Coroner; R Singh (instructed by the Treasury Solicitor) for the Home Secretary.
Whether an inquest satisfied the requirements of Art 2 European Convention in relation to a death in prison custody.
: M, the son of the Claimant, committed suicide by hanging on 14 January 1999, aged 30, at HMP Horfield in Bristol, where he was serving a sentence of life imprisonment. An inquest into his death was held in May 1999, but was quashed in judicial review proceedings for failure to enquire sufficiently into the death. A full inquest was heard over 3 days in October 2000. The issue raised was whether M's death could have been prevented and so whether a verdict involving neglect should be left to the jury: the coroner decided against this, but did indicate that the jury could give him a note which he would take into account in deciding whether to make any recommendations. The jury returned a verdict of suicide and produced a note which contained indications that they felt the prison had failed in their duty to care for M. The coroner declined to make the jury note public, but did refer to it in a letter he wrote to the Chief Inspector of Prisons.
M's mother sought an order that the coroner fully record the jury's findings as set out in their note, as a public determination of the responsibility of the Prison Service in relation to M's death. It was submitted that the inquest was inadequate for the purposes of Art 2 European Convention, which was said to impose obligations on the state (i) to take reasonable care of those in its custody; and (ii) where a death in custody has occurred, and it is arguable that the state failed to take proper steps to prevent that death, to conduct an official investigation which is capable of determining whether such a breach in fact occurred.
Introduction
1. These proceedings concern the inquest into the death of Colin Campbell Middleton, who died on 14 January 1999, aged 30, at HMP Horfield in Bristol. In these proceedings, the Claimant contends that the provisions of English law regulating the conduct of inquests are incompatible with Art 2 of the European Convention on Human Rights; and that in cases, such as the present, in which it is alleged that the deceased died whilst in the custody of the State as a result of the negligence of officers of the State, by reason of the restrictions in English law on the permissible findings of inquest juries, the holding of an inquest does not satisfy the obligations of the State resulting from his death. These contentions are contested by the Home Secretary, who is the Minister responsible for both the Prison Service and the holding of inquests.
The Facts
2. The Claimant is Colin Middleton's mother. A first inquest into his death was held on 13 May 1999, but its verdict was quashed by order of Sullivan J. for failure to enquire sufficiently into the death. The second inquest, which is the subject of these proceedings, took place between 8 and 10 October 2000. The Coroner was Mr Michael Rose. It is accepted, and indeed asserted, on behalf of the Claimant that the second inquest was a full and proper enquiry into the matters surrounding the death of Mr Middleton. The inquest took 3 full days and heard oral evidence from 11 witnesses, and there was written evidence from a further 7. The inquest investigated the circumstances immediately relating to the death, as well as the surrounding background. There was no dispute that Mr Middleton, who was serving a sentence of life imprisonment, had committed suicide on 14 January 1999. He was found suspended from a ligature. A suicide note was found in his cell. However, it was, and is, alleged that there had been substantial indications in the period before his death that Mr Middleton was suicidal; that, if proper notice had been taken of those indications by prison officers, a prison "self-harm at risk" form known as F2052SH would have been raised before his death; that, if that form had been raised and the action required by it taken, he would have been placed on "suicide watch"; and if that had been done, his suicide would have been prevented.
3. After the close of the evidence, the Coroner heard submissions on behalf of the family of the deceased and of the Prison Service as to whether the jury should be invited to consider making a finding of "neglect" on the part of the Prison Service. The Coroner ruled that the issue of neglect should not be left to the jury. He summed up accordingly. It is, I think, accepted on behalf of the Claimant that his ruling was in accordance with English law prior to the Human Rights Act 1998, as stated by the Court of Appeal in R v HM Coroner for North Humberside and Scunthorpe ex p Jamieson [1995] QB 1.
4. At the end of his summing-up, the Coroner told the jury that they could give him a note regarding any specific areas of the evidence with which they were concerned, which he would consider when deciding whether to make any recommendations arising from the death. He told the jury that any such note would not be read out. He said to them:
"Now, juries for many years past have not been allowed to … make riders, that is, things that you would like to say. You may not comment on matters other than matters I have put to you. But sometimes you feel that there are things that you must draw to my attention. There is no reason why you should not do this in the form of … not even a letter, a note to me. I do not read it out, but I take it into consideration, particularly if I feel that I need to make any recommendation, either to the prison authorities or to Her Majesty's Inspector of Prisons. And you, if you, I don't invite you to do this, but if you do, I shall certainly take it into consideration. It's a matter between you and me alone. …"
5. After the jury retired, counsel for the family made an application, heard in chambers, that any such note should be disclosed. The Coroner rejected the application.
6. When the jury returned, they determined that the deceased had killed himself whilst the balance of his mind was disturbed. At the same time, they produced a note that was handed to the Coroner.
7. After the discharge of the jury and the end of the proceedings, the Coroner showed the note to counsel for the family and for the Prison Service. It contained 4 conclusions on the facts, which indicated that the jury considered that the Prison Service had failed in their duty to care for Mr Middleton. In particular, the jury:
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(a) expressed concern that a form F2052SH had been closed by 2 officers who had no prior knowledge of Mr Middleton; and
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(b) expressed their belief that a letter of 11 January 1999 written by him "contained sufficient indication to warrant an F2052SH being opened."
If a form F2052SH had been opened on 11 or 12 January 1999, Mr Middleton would have been on "suicide watch" at the time of his death, and his suicide might have been prevented.
8. The Claimant's solicitor subsequently wrote to the Coroner inviting him to append the note to the inquisition, thereby putting the full findings of the jury into the public domain. By letter dated 15 December 2000, the Coroner declined to do so. The contents of the note have not been made public.
9. On 9 November 2000, the Coroner wrote to General Sir David Ramsbottom, HM Chief Inspector of Prisons, informing him of his concern, resulting from the inquest, as to the monitoring of life prisoners. The letter summarised the facts relating to the suicide of Mr Middleton. The Coroner's letter referred to the jury's note. He stated:
"Incidentally, the Jury were not entirely satisfied with the deceased's treatment in the Prison and sent me a note listing a number of complaints. These complaints were, no doubt, prompted by the fact that the original F2052SH had been closed after a very short period on the instigation of 2 people who did not know the prisoner. It also noted a failure in the Prison's responsibilities towards Middleton and a total lack of communication between all grades of prison staff."
10. The letter also expressed the Coroner's own concerns resulting from the inquest.
The Issues
11. The relief sought on behalf of the Claimant in her claim form is a mandatory order requiring the Coroner fully to record the jury's findings as set out in their note. The claim form expressly did not seek an order directing the holding of a new inquest. A new inquest would involve unnecessary public expense and distress to all concerned, and particularly the family of Mr Middleton. Moreover, as I mentioned above, the Claimant accepts that the circumstances surrounding his death had been fully and indeed sensitively investigated during the course of this second inquest. The Claimant's complaint relates not to the Coroner's investigation, but to the formal finding that was made as a result of it.
12. Essentially, the Claimant seeks a formal public determination of the responsibility of the Prison Service in relation to the death of her son. However, when it became clear that some of the contents of the jury note were on any basis inappropriate for incorporation in a verdict, and after discussion during the hearing, the scope of relief sought was extended to the following:
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(1) A declaration that the inquest into the death of Colin Campbell Middleton was inadequate to meet the procedural obligation in Art 2 ECHR for a thorough and effective official investigation into the death.
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(2) A declaration that in a case where a public authority was or ought to have been on notice of a real and immediate risk to the life of...
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