R v North Humberside and Scunthorpe Coroner, ex parte Jamieson

JurisdictionEngland & Wales
Judgment Date25 April 1994
Judgment citation (vLex)[1994] EWCA Civ J0425-3
Docket NumberNo. QBCOF 93/1006/D
CourtCourt of Appeal (Civil Division)
Date25 April 1994
Roy Jamieson
HM Coroner for North Humberside and Scunthorpe

[1994] EWCA Civ J0425-3

(Lord Justice Neill and Mr Justice Mantell)

Before: The Master of the Rolls (Sir Thomas Bingham) Lord Justice Mccowan and Lord Justice Hirst

No. QBCOF 93/1006/D






MR. I. MacDONALD Q.C. and MR. T. OWEN (instructed by Messrs. Ison Harrison & Company, Leeds) appeared on behalf of the Appellant.

MR. STEPHEN RICHARDS (instructed by Treasury Solicitor, London) appeared as amicus curiae.

MR. I. BURNETT (instructed by the County Solicitor, Humberside County Council, Humberside) appeared on behalf of the Respondent.


( )


THE MASTER OF THE ROLLSOn 24 January 1991 Michael Jamieson (the deceased) took his own life while serving a long sentence of imprisonment. At the inquest which followed HM Coroner for North Humberside and Scunthorpe (the coroner) directed the jury not to return a verdict in which the words "lack of care" formed a part. The jury found that the deceased had killed himself by hanging. Roy Jamieson (the applicant), the brother of the deceased, sought and obtained leave to move for an order of judicial review. He contended that the coroner had wrongly directed the jury not to consider a verdict of or a reference to lack of care. That challenge was rejected by a Queen's Bench Divisional Court (Neill LJ and Mantell J) on 9 July 1993, on both legal and discretionary grounds. The applicant appeals against that decision.


The courts have had occasion to consider the verdict "lack of care", and the circumstances in which lack of care could properly be found to have contributed to or aggravated a cause of death, in a number of cases since 1981. Despite the rulings given by appellate courts, problems continue to arise both for coroners seeking to conduct inquests and direct juries in accordance with the law as they understand it and for those interested in the death of a deceased person seeking to explore the full circumstances of the death and draw lessons which may prevent repetition. Coroners do their utmost to confine the proceedings before them within the bounds of what they consider to be proper. Interested parties not infrequently strain to pursue their quarry well beyond the bounds set by the coroner. It is not desirable that uncertainty should persist. Recognising the potential importance of our decision in this case we invited the Attorney-General to appoint an amicus to represent the public interest. The Attorney-General kindly agreed, and we have derived great help from the submissions made by Mr Stephen Richards as amicus.


This is the judgment of the Court.


The facts


We take the summary of the relevant facts verbatim from the judgment of Neill LJ, which (subject to one qualification) was accepted as accurate and adequately comprehensive by counsel for the applicant :

"The deceased was born on 5 September 1957. At the time of his death on Thursday 24 January 1991 he was aged 33. On 3 December 1981 the deceased, then aged 24, was sentenced to life imprisonment for murder, attempted murder, robbery, the possession of a firearm and other offences. The judge made a recommendation that the deceased should serve a minimum term of 30 years. At all times after he was sentenced to imprisonment the deceased was a category A prisoner.

On 1 June 1990 the deceased was transferred to Full Sutton Prison in York. On 16 October 1990 he requested a move nearer home to Wormwood Scrubs. In the form requesting a permanent transfer nearer home the deceased gave as his reasons :

"Due to mental deterioration through lack of contact with personal family with other problems. Living as though a mental vice is crushing my mind."

On 18 October 1990 Governor Dickinson recorded that the request fell outside his area of authority and that it needed to be transmitted to the category A section in the Directorate of Custody. Mr Dickinson added :

"Visits are not being received and I believe a move to a CAT A Establishment closer to his home may be in the best interests of all concerned."

A reply from the category A section was received at the prison on 24 January 1991 but the deceased had not seen the letter before he died.

On 25 November 1990 the deceased wrote to his mother. In this letter he said he did not wish to go on living any longer and that he felt happy about the thought of dying. He added that he was going to be totally selfish and that he had decided to starve himself to death. On receipt of this letter his mother telephoned the welfare officer at the prison who told her that he had already spoken to the deceased about the letter. The mother made arrangements to visit the deceased and spent two hours with him at Full Sutton on 23 December.

On 26 December 1990 the deceased cut his wrists and forearms. Dr Tina Shaw, who was the permanent medical officer at the prison, treated him and inserted 18 stitches in his left arm. His right arm did not require stitching. While treating him Dr Shaw had a discussion with the deceased in the course of which he said he was depressed. Dr Shaw asked him if he had intended to kill himself by cutting his arms. He replied that he felt "better now he had done it" but that he "wished it had been successful". Dr Shaw decided that the deceased should be transferred to the prison hospital where he would have the benefit of being allowed to associate with the others in the ward.

On 7 January 1991 the deceased asked Dr Shaw whether he could go back to a cell on C wing. After a discussion it was agreed that he would stay in the hospital for a few more days. On 10 January the deceased again asked to go back on the wing. This time Dr Shaw agreed because the deceased seemed to be making some progress and because he said that he no longer wanted hospital treatment. On 14 January, however, the deceased was readmitted to the hospital because the prison staff on the wing were worried that his condition had deteriorated. Two days later, on 16 January, the deceased expressed a wish to go into the segregation unit at the prison but no action was taken at that stage.

On 18 January Dr Susan Shaw, a consultant psychiatrist, visited the prison and in the course of her visit spoke to the deceased. It was arranged that the deceased would have a consultation with Dr Susan Shaw on Friday 25 January.

On the following day, 19 January, the deceased asked again to go to the segregation unit. He said that he was not ill and that he did not want to go back to C wing. Dr Tina Shaw agreed to the move, though (according to her evidence at the inquest) she regarded it as "a very negative move". Dr Shaw told the deceased that he could come back to the hospital if he had any problems or if he was not happy.

At 1440 hours on Wednesday 23 January 1991 the deceased rang the bell in his cell in the segregation unit. When an officer arrived the deceased asked if he could go "special sick" as he was feeling anxious. A message was sent to the hospital and Mr Weldrick, a hospital prison officer, went to the segregation unit and took the deceased back at once to the hospital wing. He was then placed in a single cell in the hospital wing. According to the evidence of Dr Shaw this was the cell which he had occupied before he returned to the segregation unit on 19 January. It seems that on his return during the afternoon there were only three occupants of the four bed ward, but another prisoner was admitted to the ward later that evening. When occupying a single cell in the hospital wing the deceased was able during the day to associate with the prisoners in the ward.

On the afternoon of Thursday 24 January Mr Alan Morris, the senior hospital officer, received a letter from the category A section in London. The letter was to the effect that the deceased's application for a move had not been approved, though it was suggested that he should apply for a transfer to a prison in the south of England so that he could have a series of "accumulated visits". The system of "accumulated visits" is a system whereby a prisoner is transferred to a prison near his home for a period of about a month so that he can receive a number of visits during the month which would otherwise have been spread out over a year. Mr Morris decided that it would not be wise to give the deceased bad news at a time when there was not much support available to him. He decided to wait until the next morning.

On the night of 24/25 January 1991 the hospital wing was manned by an agency nurse and two prison officers, Mr Wiley and Mr Wood. The agency nurse was Mrs Kowalczyk. The nurse, who is a State Enrolled Nurse, was on duty from 9 pm in the evening until 8 am the next morning. Neither the nurse nor the prison officers were told to keep any particular watch on any prisoner. During the night Mr Wiley and Mr Wood made hourly checks on the prisoners. On each occasion they observed the deceased apparently sitting on his bed.

Mr Weldrick came on duty in the hospital wing at 8 am on 25 January. At 8.10 am he went to the deceased's cell and opened the door hatch to ask him whether he wanted breakfast. The deceased, who appeared to be looking out of the window behind the curtains which were drawn, made no reply. Mr Weldrick called for another officer and together they entered the cell. On pulling the curtains aside they found that he was hanging from a piece of white cloth. It was at once apparent that the deceased was dead."


The qualification is this. When the deceased was accommodated in the...

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