R Kelly Anne Boyce v HM Senior Coroner for Teesside and Hartlepool
| Jurisdiction | England & Wales |
| Judge | Belcher |
| Judgment Date | 21 January 2022 |
| Neutral Citation | [2022] EWHC 107 (Admin) |
| Court | Queen's Bench Division (Administrative Court) |
| Docket Number | Case No: CO/4780/2020 |
[2022] EWHC 107 (Admin)
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
ADMINISTRATIVE COURT
HER HONOUR JUDGE Belcher
Case No: CO/4780/2020
and
Dr Anton Van Dellen (instructed by Watson Woodhouse Limited) for the Claimant
Mr Jonathan Hough QC (instructed by Middlesbrough Council, Legal and Governance Services) for the Defendant
Mr Jonathan Walker (instructed by Middlesbrough Council, Legal and Democratic Department) for the First Interested Party
Mr Sam Faulks (instructed by Taylor Law) for the Second Interested Party
Hearing date: 14 December 2021
Approved Judgment
The Claimant, Kelly Anne Boyce, is the mother of Grace Ann Peers (“Grace”) who died on 10 September 2018, when she was 15 years old. At the time of her death, Grace was in the care of Middlesbrough Borough Council (“MBC”) (the First Interested Party) which had placed her at Farm House, a private care home operated by Tees Valley Care Ltd (“TVC”) (the Second Interested Party). On 28 September 2020, the Defendant Senior Coroner (“the Coroner”) decided that the inquest touching upon Grace's death shall not be a full Article 2 European Convention on Human Rights (“the Convention”) inquest. The Claimant challenges that decision in these proceedings.
The Defendant is a judicial officer. She has participated in these proceedings in a non-adversarial role both by filing submissions in response to the Claimant's Grounds, and by instructing counsel to appear before me in order to explain the factual background and her decisions, as well as to assist the Court on matters of coronial law and practice. I am grateful for that assistance. References to the trial bundle in this judgment will be by reference to the relevant page or page numbers contained in square brackets.
Grace was born on 25 June 2003. In February 2017 a care order was made placing Grace in the care of MBC. Grace was initially placed in the care of her maternal grandmother, but that placement broke down and in May 2018, Grace was moved to a children's home in Darlington. On 26 June 2018 Grace was placed at Farm House, initially for a six week placement pending the arrangement of a longer term placement elsewhere.
On 5 September 2018 Grace started her new school year. She had dyed her hair purple and following a confrontation with staff at the school, Grace was excluded from school. On 7 September 2018, at a reintegration meeting at the school, Grace was abusive and was excluded for two further days. On 10 September 2018, Grace was tragically found hanging from a scarf in the shower cubicle of her room at Farm House. A post-mortem examination gave the cause of death as cerebral anoxia due to hanging.
The Coroner opened an inquest into Grace's death. On 3 June 2019 the Coroner made directions that interested persons were to file written submissions as to Article 2 engagement. In a written ruling dated 1 July 2019 the Coroner determined that there was insufficient evidence that there had been a real and immediate risk to Grace's life and accordingly that there had been no breach of the operational duty under Article 2. Ground Four of the Claimant's grounds challenged this decision, notwithstanding that the claim in this matter was not filed until December 2020. However, at the commencement of the hearing in front of me, Dr Van Dellen advised me that Ground Four was no longer pursued, and I shall make no further reference to that Ground in this judgment.
Notwithstanding her conclusion that there was no breach of the operational duty under Article 2, the Coroner indicated that she remained open to considering whether there were flaws in higher level systems which gave rise to an arguable breach of the Article 2 general duty of the state. She directed that independent expert evidence be obtained into a number of specific matters [400 – 401] all of which are directed to the question of whether Farm House had been an appropriate venue for Grace given her needs and requirements.
Dr Charles Stanley, a Consultant in Child and Adolescent Psychiatry, provided a report to the Coroner dated 6 December 2019 [399 – 456], and an addendum report dated 9 December 2019 [483–484] produced following the receipt by Dr Stanley of additional documents.
In a written ruling dated 28 September 2020 [66–69], the Coroner accepted that there were clearly issues with the systems and procedures operated by MBC social services department and by Farm House. However, she concluded that it was not arguable that there was a real and substantial chance that improved systems and procedures would have saved Grace's life, given the level of care she in fact received at Farm House. She continued:
“On the documentary evidence that I have considered I am of the opinion that this inquest shall proceed as a Jamieson, and not as a Middleton inquest; the four questions that will be answered at the end of the inquest shall not be extended to include “how and in what circumstances”. I shall keep an open mind and if it becomes appropriate, the matter of engagement of Article 2 can be reconsidered at the conclusion of the inquest.
I remind myself that a determination as to the applicability of Article 2 will not affect the scope of the inquest, just the conclusion. I am still likely to need to consider issues regarding procedures and systems when considering my duty under PFD” [69]
The four questions referred to by the Coroner are the four questions referred to in Section 5(1) Coroners and Justice Act 2009 (“ CJA 2009”) which provides that an inquest has the purpose of ascertaining the answers to four principal factual questions: who the deceased was; and how, when and where he/she came by his/her death. Section 10 CJA 2009 provides that the determinations at the end of an inquest must answer these questions.
The Coroner's references to Jamieson and Middleton inquests are shorthand references readily recognised by those practising in coronial law, and the names derive from case law involving parties with those names. There is no dispute that a Jamieson inquest is limited to an enquiry as to how in the sense of by what means the deceased came by her death. A Middleton inquest applies to those inquests where the Article 2 procedural obligation is engaged and requires the expression “how” the deceased came by his/her death to be read as meaning “by what means and in what circumstances”. This is often referred to as the enhanced investigative duty.
The Factual Background
I am grateful to Mr Hough for the following summary of the factual background which I have taken from his skeleton argument, and which I do not understand to be in dispute. I acknowledge that it is based upon written evidence and records before the Coroner and that it does not reflect any predetermined views of the Coroner on the evidence she may hear in due course at the Inquest. The figures in square brackets are references to the trial bundle.
“Grace was born on 25 June 2003. She first came to the notice of the Council in 2010, when she was aged seven and she began exhibiting difficult and sometimes violent behaviour towards her family members. In June 2012, Grace disclosed that she had been abused by her mother's then partner, as a result of which she and her younger brother were made subject to child protection plans. In December 2015, following further allegations by Grace that she had been physically abused, she was made the subject of a child protection enquiry. Her behaviour remained challenging and she had become alienated from her mother and immediate family. At this stage, mental health services became involved with Grace and a full autism assessment was made. The conclusion was that Grace did not satisfy the ICD 10 criteria for a diagnosis of autism, but that she was suffering from an attachment disorder. See para. 3.3 of Dr Stanley's report [404]
Between February and May 2016, Grace was in the care of her maternal grandmother, Mrs Peers. She was placed in foster care in the latter part of 2016, while care proceedings were pursued. In February 2017, a care order was made under section 31 of the Children Act 1989 in favour of the council, after which Grace was again placed with her grandmother. She remained with Mrs Peers until May 2018, when Grace had to be moved because of an incident in which she assaulted her grandmother (who was in poor health and by this time was physically intimidated by Grace). By this point, Grace was known to be sexually active and to be using alcohol and cannabis regularly. See para. 3.4 of Dr Stanley's report [404–5].
From 2 May 2018, Grace was placed in Baydale House, a residential children's home in Darlington. While there, she made a disclosure of sexual abuse by a former partner of her mother. Grace remained at Baydale House until 20 June 2018 when she was moved as a result of apparent sexual activity with a male resident. See para. 3.5 of Dr Stanley's report [405–6].
With effect from 26 June 2018, Grace was placed at Farm House, a recently established small residential home for young people with complex behavioural needs. At this time, Grace was studying for GCSEs at Outwood Academy, Acklam, and was about to enter a new school year. The placement was always intended as a six-week interim measure while a longer-term placement was arranged. See para. 3.7.1 of Dr Stanley's report [406–7]. The referral document for the placement [147–58] contained modestly inconsistent references to risks of self-harm (with one section grading the risk as low to medium, with no evidence to date; and another putting the risk as medium). On the day of her arrival at Farm House, Grace and her social worker had a...
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