R (Sacker) v HM Coroner for West Yorkshire
| Jurisdiction | England & Wales |
| Judge | Lord Justice Pill,Mummery LJ,Latham LJ |
| Judgment Date | 27 February 2003 |
| Neutral Citation | [2003] EWCA Civ 217 |
| Court | Court of Appeal (Civil Division) |
| Date | 27 February 2003 |
| Docket Number | Case No: C3/2002/1633 |
[2003] EWCA Civ 217
IN THE SUPREME COURT OF JUDICATURE
COURT OF APPEAL (CIVIL DIVISION)
ON APPEAL FROM THE QUEEN'S BENCH DIVISION
ADMINISTRATIVE COURT (MR JUSTICE TUCKER)
Royal Courts of Justice
Strand,
London, WC2A 2LL
Lord Justice Pill
Lord Justice Mummery
and
Lord Justice Latham
Case No: C3/2002/1633
Richard Gordon QC and Stephen Cragg (instructed by Messrs Howells (Sheffield) for the Appellant
James Findlay (instructed by City of Wakefield MDC, Central Services Department) for the Respondent
This is an application for permission to appeal with appeal to follow if permission is granted. It is made in relation to the order of Tucker J on 4 July 2002 refusing Ms Helen Sacker permission to apply for judicial review of a decision of HM Coroner for West Yorkshire (Eastern District) on 11 October 200The Coroner declined to leave to a Coroner's jury the opportunity to bring in a verdict including neglect at the inquest into the death of Sheena Creamer who died at HMP New Hall on 7 August 2000, aged 22 years. The claimant Ms Helen Sacker is the mother of Sheena Creamer. She seeks to quash the inquisition and an order that a fresh inquest be held.
The application for judicial review was filed on 25 April 200Tucker J refused it on the ground of delay before the claim was filed and on the merits. The claimant seeks a short extension of time in which to apply for permission to appeal. She seeks permission to appeal and permission to apply for judicial review. If permission is granted, she invites the Court itself to decide the application for judicial review and not to remit it to the High Court. No civil or criminal proceedings have been commenced.
Ms Creamer had been held on remand in HMP New Hall for an alleged offence of dishonesty for over a week before her death. At a remand hearing at the Magistrates' Court on 4 August 2000, she had become very upset and a prison officer had opened a form F2052SH on that date. The form is headed "Self harm at risk form" and is stated on its face to be a form which "may be raised by any member of staff who is concerned about a prisoner". As a result of the form being opened, Miss Creamer was taken to the health care centre at the prison. She was going through a drug detoxification at the time.
The deceased remained subject to the F2052SH form until her death. However, on 5 August she was examined by a locum doctor, Dr Spivack, who was unaware of the procedure which went with the form. He referred her back to the residential wing at the prison. She was placed in a single cell and made subject to half-hourly visits. There was a modesty curtain around the toilet. On the 11.30 pm check on the night of 6–7 August, Miss Creamer was found hanging from the window by the privacy curtain and was pronounced dead on arrival at the hospital.
The Inquest
The Coroner read the Inquisition at the conclusion of the inquest:
"That an Inquisition taken for our Sovereign Lady the Queen at Wakefield on the 14 th day of August 2000 and by adjournment on the 9 th, 10 th, 11 th and 12 th of October 2001 before and by me David Hinchliff one of her Majesty's Coroners for the said County the following matters were found by a majority of 9 to 2. That the name is that of Sheena Dawn Lisa Nicola Marie Creamer, the injury of disease causing death was 1(a) hanging by ligature and (b) the time place and circumstances is that the deceased was a remand prisoner at Her Majesty's Prison New Hall. She was further remanded to Prison by Sheffield Magistrates' Court on 4 th August 2000 and was admitted to the Medical Centre, she was moved to the Residential Wing cell C215 on 6 th August 2000 where she was discovered hanging by a ligature by a Patrolling Officer. An ambulance took her to Pinderfields General Hospital where she was declared dead on arrival at 0400 hours on 7 th August 2000 and the Jury's conclusion by majority is that Sheena killed herself … ."
Before closing the Inquest, the Coroner referred to Rule 43 of the Coroner's Rules which provides:
"A coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the inquest is being held may announce at the inquest that he is reporting the matter in writing to the person or authority who may have power to take such action and he may report the matter accordingly."
The Coroner stated:
"Just before I formally conclude this Inquest I intend now making an announcement pursuant to Rule 43 of the Coroner's Rules that it is my intention to write to the Prison Department and inform them as to my grave concerns regarding the Locum Medical Officer at New Hall Prison on this occasion not having a working knowledge of the Form 2052SH procedures. I regard the Form 2052SH as a vital tool in identifying those prisoners who are vulnerable and at risk of self harm or suicide and I take an extremely dim view of the fact that somebody in such an important position as a Medical Officer albeit a Locum on this occasion demonstrated such a scant understanding of what is such an important provision and therefore I shall write to the Head of the Prison Service pointing out my concerns pursuant to this Rule."
In his letter to the Director General of the Prison Service dated 31 October 2001, the Coroner set out the findings at the inquest and added:
"At the conclusion of this inquest I made an announcement pursuant to Rule 43 of the Coroners' Rules 1984, that I would report the matter in writing to the person or authority who may have power to take such action to prevent the recurrence of fatalities similar to that in respect of which the inquest was being held, on the basis of my concerns regarding a locum medical officer serving New Hall Prison at that time. I heard evidence from Dr Leslie D Spivack, the said locum medical officer, who, in the course of his evidence, showed a lack of knowledge and understanding of the 2052SH procedures. Dr Spivack incorrectly completed this document and clearly stated that he did not fully understand the 2052SH system and documentation
It is a matter of grave concern to me that any medical officer working within the prison system should not understand such a vital component in preventing self harm and suicide to the inmate population.
I require an assurance from you that there will be adequate and appropriate training of all prison medical staff of the 2052SH system and procedures before they are allowed to practice within the prison service.
If you require a transcript of Dr Spivack's evidence, then this can be supplied.
I would be most grateful if my recommendations can be given serious consideration and I await your own observations."
The Issue
The issue in the case is whether the Coroner ought to have acceded to the submission of Mr Cragg, counsel for the claimant at the inquest, that the jury should have been given an opportunity to add to a verdict that the deceased had killed herself a rider providing that "neglect had contributed" to the death. Reliance is placed on the decision of this Court in The Queen on the application of Amin and The Queen on the application of Middleton v Secretary of State for the Home Department [2002] EWCA Civ 390 (" Middleton") where the judgment of the Court was given by Lord Woolf CJ on 27 March 2002, that is after the inquest. The Coroner did leave to the jury the possibility of bringing in a verdict of accidental death, a verdict of death by misadventure and an open verdict.
The Authorities
Rule 36 of the Coroners Rules 1984 provides:
"(1) The proceedings and evidence at an inquest shall be directed solely to ascertaining the following matters, namely-
(a) who the deceased was;
(b) how, when and where the deceased came by his death;
(c) the particulars for the time being required by the Registration Acts to be registered concerning the death.
(2) Neither the coroner nor the jury shall express any opinion on any other matters."
Constraints are placed on what may be included in a verdict by Rule 42 of the Rules:
"No verdict shall be framed in such a way as to appear to determine any question of – (a) criminal liability on the part of a named person, or (b) civil liability."
In R v H M Coroner for North Humberside and Scunthorpe ex p Jamieson [1995] QB 1, Sir Thomas Bingham MR set out in a series of propositions the principles to be applied under the Coroners Act 1988. That case also involved an inquest which followed a prisoner hanging himself in prison and issues arose as to possible neglect by the Prison Service. Having stated, in proposition 10, that neglect "can rarely, if ever, be an appropriate verdict on its own", a proposition not disputed in the present case, the Master of the Rolls continued:
"(11) Where it is established that the deceased took his own life, that must be the verdict. On such facts, as the applicant in the present case accepted, there is no room for a verdict of neglect (or, as he would have put it, lack of care). It is also inappropriate in such as case, as the applicant also accepted, to describe that cause of death as aggravated by neglect (or lack or care). On certain facts it could possibly be correct to hold that neglect contributed to that cause of death, but this finding would not be justified simply on the ground that the deceased was afforded an opportunity to take his own life even if it was careless (as that expression is used in common speech or in the law of negligence) to afford the deceased that opportunity. Such a finding would only be appropriate in a case where gross neglect was...
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