R (Sacker) v West Yorkshire Coroner
| Jurisdiction | England & Wales |
| Judgment Date | 11 March 2004 |
| Neutral Citation | [2004] UKHL 11 |
| Date | 11 March 2004 |
| Court | House of Lords |
ex parte Sacker (FC)
[2004] UKHL 11
HOUSE OF LORDS
ORDERED TO REPORT
The Committee (Lord Bingham of Cornhill, Lord Hope of Craighead, Lord Walker of Gestingthorpe, Baroness Hale of Richmond and Lord Carswell) have met and considered the cause Regina v. Her Majesty's Coroner for the County of West Yorkshire (Appellant) ex parte Sacker (FC) (Respondent). We have heard counsel on behalf of the appellant and respondent.
This is the considered opinion of the Committee.
The respondent Helen Sacker is the mother of Sheena Creamer, who died on 7 August 2000 while she was being held on remand at HM Prison New Hall, West Yorkshire. An inquest was conducted into her death by the appellant, HM Coroner for West Yorkshire (Eastern District), from 9 to 12 October 2001. The inquisition which was read by the appellant at the end of the inquest recorded the conclusion of the jury, by a majority of 9 to 2, which was that Ms Creamer had killed herself. Counsel for the respondent had submitted that the jury should be given an opportunity to add the words "contributed to by neglect" to their verdict. The appellant declined to do this, so the jury were not given that opportunity. On 4 July 2002 Sir Richard Tucker refused the respondent permission to apply for judicial review of the appellant's decision. On 27 February 2003 the Court of Appeal (Pill, Mummery and Latham LJJ) allowed the respondent's appeal against the decision of the judge, quashed the inquisition and ordered a fresh inquest.
The question which is before your Lordships in this appeal is whether the appellant should have directed the jury that they could add a rider to their verdict to indicate that systemic neglect had contributed to Ms Creamer's death. But the case raises a number of other issues of general public importance about the conduct of inquests and the verdicts that may result from them. This is because article 2 of the European Convention for the Protection of Human Rights and Fundamental Freedoms, which provides that "everyone's right to life shall be protected by law," has now been incorporated into domestic law by the Human Rights Act 1998. These issues are of particular concern in cases such as this, where the death was caused by suicide while the deceased was in custody. In view of its importance the appeal was heard together with R v HM Coroner for the Western District of Somerset, Ex p Middleton [2004] UKHL 10. The opinion which has been delivered in that case provides the background to the way in which the question in this case must be decided.
Suicide in prisons
It is important, in order to set this case into its proper context, to appreciate the nature and scale of the problem of self-harming behaviour by prisoners who are held in prison establishments, especially those holding women. The Joint Committee on Human Rights which was appointed by the House of Lords and the House of Commons to consider matters relating to human rights in the United Kingdom is at present engaged on an inquiry into deaths in custody: see Deaths in Custody: Interim Report, 26 January 2004 (HL Paper 12/HC 134). In response to its call for evidence the Committee received a memorandum from HM Prison Service for England and Wales dated 18 August 2003: Ev 26–32. In this memorandum the Director General of the Prison Service, Phil Wheatley, acknowledges that any death in custody is a terrible tragedy that brings its duty of care to people in custody into sharp focus. Reducing suicides and self-harm in prisons is said by him to be a key objective. He points out that a great deal of work has been and continues to be done in this area, but that there are, regrettably, no simple solutions and that the reasons for self-inflicted deaths are complex.
For many years the standard method of reducing the risk of prison suicides was to observe prisoners who were thought to be at risk at fixed intervals. The Tumin Review on Suicide, Report of a Review by Her Majesty's Chief Inspector of Prisons for England and Wales of Suicide and Self-harm in Prison Service Establishments in England and Wales, December 1990 (Cm 1383), drew attention to the dangers which were inherent in this practice and recommended that the period between observations should be designed to meet the perceived needs of the individual prisoners concerned. In December 1997 Ms Joyce Quin, the Minister for Prisons, asked the then Chief Inspector of Prisons, Sir David Ramsbotham, to carry out a thematic review of suicide and self-harm in prison service establishments in England and Wales to follow up that undertaken by Sir Stephen Tumin. This was in response to concern expressed by the Director General of the Prison Service about the increasing number of deaths in custody and as to whether everything possible was being done to prevent them. The Ramsbotham Report, Suicide is Everyone's Concern, A Thematic Review by HM Chief Inspector of Prisons for England and Wales, May 1999, noted that, in contrast with the falling rate of suicide in the community, the rate in prison had increased dramatically. It had more than doubled between 1982 and 1998, and a marked increase had taken place among prisoners who were unsentenced.
In a section entitled "Understanding Suicide" the Ramsbotham Report noted the complexity of the characteristics that lead to the suicide state and the need to understand it at several levels. It was possible to identify a number of broad types of prisoners who were at risk of suicide. One of these was prisoners aged between 16 and 25 with a history of previous self-injury, whose distress was acute and who were particularly vulnerable to the impact of imprisonment. In para 2.11 it was noted that the role of staff must be to understand the complexity of this experience, to alleviate the pain of isolation and to help the individual to take steps that will bring about an end to their pain through means other than killing themselves.
In a section entitled "The Effectiveness of Current Practice" the Ramsbotham Report set out the main features of the suicide prevention strategy that had been adopted by the Prison Service in 1994 in the light of independent research which it had commissioned into the behaviour and characteristics of male prisoners who attempt suicide or harm themselves. These included greater responsibility for all prison staff in caring for the suicidal, a move away from reliance on health care staff and the introduction of a new form for managing those considered as being at risk (form F2052SH). It was found that there was an evident inconsistency in the effectiveness of different suicide awareness teams that had been set up and that, although suicide prevention policies were in place across the Prison Service, there was little differentiation within them between different types of prisoner. The need for different strategies was emphasised having regard in particular to the vulnerable, uncertain and impulsive nature of young prisoners, especially those on remand. Attention was drawn to the proper use of the "At Risk" Form F2052SH, of which this was said, in para 5.37:
"This form is opened when any member of staff considers a prisoner to be at risk. It was designed in considerable detail to manage the measures to be taken to support an individual at a time of a suicidal crisis to the point where risk was reduced and the form could be closed. The form is only intended however as a framework and following the stages of the form should not be the end in itself. Writing on the form is not what sees someone through a crisis. If the contents become clichéd and repetitive, the piece of paper becomes meaningless, and worse, staff quite wrongly feel they have done their job. This is not to argue against the role of the form, but to emphasise that it is not the most important feature of the strategy and it should not be relied on as the sole mechanism for intervention. The most important outcome of any process is that the prisoner concerned receives the help he/she needs to get through the crisis."
The Report concluded in para 5.58 that the Prison Service policy towards the prevention of suicide was fundamentally sound when applied in its entirety, but that the modern history of the Prison Service revealed that systems are only as effective as the competence and dedication of those who administer them.
In Chapter 6 the Ramsbotham Report put forward principles on which a revised strategy for suicide prevention in local prisons, such as HM Prison New Hall, should be built. The Chief Inspector drew attention to the importance of this exercise in his Preface to the Report, which included this paragraph:
"The particular significance of this review is that it affects every person every time they come into custody. Death and bereavement inevitably touch us all in some way, and, when a prisoner dies in prison, his or her family and friends are bereaved in the same way as anyone else. But there is an added dimension to a death in prison. Firstly family and friends do not just lose a loved one, they lose him or her in very painful circumstances, separated from them and in conditions that they do not fully appreciate. In addition staff and prisoners, living and working with the person, are also deeply affected, and have to come to terms with their bereavement as well as that of the family. Thus the impact of a death in custody is compounded by a number of additional factors and emotions, which must be acknowledged, but are difficult to understand objectively. One suicide is one too many, but, regrettably, there will always be deaths in prison, however...
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