R (on the application of Maughan) v HM Senior Coroner for Oxfordshire
| Jurisdiction | England & Wales |
| Judge | Lord Reed PSC,Lady Arden,Lord Kerr,Lord Wilson,Lord Carnwath |
| Judgment Date | 13 November 2020 |
| Neutral Citation | [2020] UKSC 46 |
| Year | 2020 |
| Court | Supreme Court |
Neutral Citation: [2020] UKSC 46
Judges: Lord Reed PSC, Lady Arden, Lord Kerr, Lord Wilson, Lord Carnwath
Court: Supreme Court
Facts: The deceased was found in his prison cell hanging from a ligature. He had a history of mental health difficulties and had threatened self-harm the previous evening. At the inquest the Senior Coroner decided that the evidence as to the deceased's state of mind was insufficient for the jury to safely return a short-form conclusion of suicide, as it could not demonstrate to the criminal standard of proof that he had intended to take his own life. The Senior Coroner allowed the jury to return a narrative conclusion regarding the death, on facts they found proved to the civil standard. The jury concluded in their narrative that the deceased had deliberately tied a ligature around his neck and suspended himself, and that on the balance of probabilities he had intended to fatally hang himself. The deceased's brother brought a claim for judicial review, arguing that in cases of suicide a jury should apply the criminal standard of proof. The Divisional Court dismissed the claim, holding that the civil standard applied. The Court of Appeal dismissed the appeal. The claimant appealed.
Appearances: K Monaghan QC and J Bunting, instructed by Matthew Gold & Co Ltd, for the claimant; A Hewitt, instructed by Oxfordshire County Council Legal Department, for the coroner; J Hough QC, instructed by Treasury Solicitor, for the Chief Coroner, intervening; A Straw, instructed by Hickman & Rose, for INQUEST, intervening.
Lady Arden (with whomLord Wilsonagreed):
1. This appeal arises out of the inquest held into the death of Mr James Maughan. It concerns the standard of proof, or degree of conclusivity, required for the determination of the result of an inquest into a death where the question is whether the deceased committed suicide. The result of an inquest may be given in a single short form conclusion (using simply the word suicide) and/or in a brief narrative statement (“a narrative conclusion”). This appeal has to consider whether the degree of conclusivity is the same in both cases, and what it is.
2. There is nothing in the relevant primary legislation, which is the Coroners and Justice 2009 Act (“the 2009 Act”), about this. However, Note (iii) to the form for recording the results of an inquest prescribed by the Coroners (Inquests) Rules 2013 (SI 2013/1616) (“the 2013 Rules”) states the standard of proof for narrative conclusions is on a balance of probabilities, which is the rule (“the civil rule”) for civil proceedings, and for short form conclusions of ‘suicide’ and ‘unlawful killing’ it is the criminal standard, so the coroner or jury must be sure, and that means that they are satisfied beyond reasonable doubt. The civil rule applies in civil proceedings even if the issue is whether someone committed a criminal offence. A coroner's inquest is not a criminal proceeding. At the time of the 2013 Rules, the common law was understood to be as stated in Note (iii). As I shall explain, there were at one time links between inquests and criminal proceedings. The 2013 Rules concretised the differential standard for short form and narrative conclusions in the Note (iii). One of the issues on this appeal is whether that approach correctly reflects the common law, either historically or currently.
3. Two elements must be established before suicide can be found: it must be shown that the deceased took his own life and that he intended to kill himself (or another): see Jervis on Coroners, 14th ed (2019), para 13.67 and Kenny's Outlines of Criminal Law, 17th ed (1958), p163.
4. It may happen in one and the same inquest that the narrative conclusions find facts which in law mean that the deceased committed suicide and yet that conclusion cannot be recorded as a short form conclusion. The Divisional Court saw the logical difficulty in a situation where there might be narrative findings showing that the two elements of suicide were satisfied and yet no short form conclusion of suicide: [2019] 1 All ER 561, [2018] Inquest LR 225. It held:
“A narrative conclusion to the effect that on the balance of probabilities the deceased did a deliberate act which caused his own death intending the outcome to be fatal clearly amounts to a conclusion that the deceased committed suicide whether or not the word ‘suicide’ is used. It is sophistry to say that such a conclusion is not one of suicide because the required standard of proof has not been met. The standard of proof even if referred to in the record of inquest, as it was in this case, is not itself part of the substantive conclusion adopted by the coroner or jury. It is simply a statement of the evidential test which must be met in order to reach a particular conclusion. If the standard of proof required to determine that the deceased committed suicide is the criminal standard and the necessary facts have been proved only on the balance of probabilities, this does not mean that a conclusion which records those facts is not one of suicide. It means that the coroner or jury cannot lawfully reach that conclusion.” (para 25)
5. Tragically, early on 11 July 2016, the appellant's brother, Mr James Maughan, was found in his prison cell hanging by a ligature from his bedframe. He was pronounced dead. He had had a history of mental health issues and was agitated on the previous evening and threatened self-harm. At the inquest into the circumstances of Mr James Maughan's death, the coroner, the Senior Coroner for Oxfordshire, applying the Chief Coroner's Guidance No 17: Conclusions: Short-Form and Narrative (referred to below as “Guidance No 17 issued by the Chief Coroner), decided that the jury could not safely reach a short form conclusion of suicide on the basis of the criminal standard of proof, that is, on the basis that the jury was sure that Mr James Maughan had committed suicide. Nonetheless, the coroner considered that the jury should have the opportunity to make a narrative statement of the circumstances of Mr James Maughan's death on a balance of probabilities. The jury answered the questions put to them by saying that the deceased had a history of mental health issues and that on a balance of probabilities the deceased intended fatally to hang himself and that increased vigilance would not have prevented his death. There was no short form conclusion of suicide. The appellant submits that this course was not open in law on the legal requirements as to standard of proof. If those standards were correctly applied, no issue is taken on the findings themselves.
6. The first respondent to this appeal is Senior Coroner for Oxfordshire, who conducted the inquest and who understandably makes no submissions on this appeal. The first intervener is Chief Coroner of England and Wales, for whom Mr Jonathan Hough QC appears.
7. INQUEST, a charity with expertise in relation to state-related deaths and their investigation, with the permission of the court, intervene in this appeal (as they had done in the Court of Appeal) and Mr Adam Straw made submissions on their behalf.
8. Longer, more judgemental narrative conclusions, as used by the coroner's jury in this case, are relatively new. They result from the recent transformation of many inquests from the traditional inquiry into a suspicious death into an investigation which is to elicit the facts about what happened, and in appropriate cases identify lessons to be learnt for the future. This is the position in inquests which the state is now required to carry out because of the European Convention on Human Rights (enforceable in the domestic law of England and Wales since 1 October 2000). Article 2 of the Convention protects the right to life. One of the consequences of this is that there must generally be an effective investigation of deaths which occur while a person is in the custody of the state (“state-related deaths”), and one of the ways in which this obligation may be discharged is by holding a coroner's inquest, in which the next of kin of the deceased can participate. The relevant principles of domestic law have been established by decisions of the courts, including, in particular, the decision of the House of Lords in R (Middleton) v West Somerset Coroner[2004] 2 AC 182, [2004] Inquest LR 17 (“Middleton”).
9. In his written submissions, the Chief Coroner states that an Art 2 inquest:
“opens up the field for conclusions about underlying or contributory causes, such as failures to prevent suicide in prison. It may require a coroner to deliver (or elicit from a jury) a more extensive and judgmental form of narrative conclusion. The manner of eliciting such a conclusion in a jury case is for the coroner's discretion but it is often done by means of questions (as in this case).” (para 19)
10. This is confirmed by the case of Scholes v Secretary of State for the Home Department[2006] HRLR 44, [2006] Inquest LR 180, which came before Pill LJ and myself in the Court of Appeal. It concerned a vulnerable 16-year-old boy, Joseph Scholes, who was sent to a young offender institution instead of a secure home for boys of his age and who shortly thereafter hanged himself. The inquest revealed a worrying situation with regard to the detention of young offenders and the Secretary of State was required to take steps to improve the situation. There had to be an increase in the number of places available in secure homes for such individuals. Even though his mother's attempt to obtain a further inquiry failed, several improvements in the system resulted from the...
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