The Queen (on the application of Maureen Speck) v HM Coroner for District of York NHS England and Another (Interested Parties)
| Jurisdiction | England & Wales |
| Judge | Sir Brian Leveson PQBD,Mr Justice Holroyde |
| Judgment Date | 12 January 2016 |
| Neutral Citation | [2016] EWHC 6 (Admin) |
| Docket Number | Case No: CO/4444/2015 |
| Court | Queen's Bench Division (Administrative Court) |
| Date | 12 January 2016 |
[2016] EWHC 6 (Admin)
THE PRESIDENT OF THE QUEEN'S BENCH DIVISION
( Sir Brian Leveson)
Mr Justice Holroyde
Case No: CO/4444/2015
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
ADMINISTRATIVE COURT
Royal Courts of Justice
Strand, London, WC2A 2LL
Mr J-P Swoboda (instructed by Ardent Law) for the Claimant
Rt. Hon. M O'Brien QC (instructed by York City Council) for the Defendant
Mr M Rawlinson (instructed by DAC Beachcroft LLP) for the First Interested Party
Ms S Knight (instructed by Bevan Brittan LLP) for the Second Interested Party
Hearing dates: 3 rd November, 2015
Miss Toni Speck died at Fulford Road Police Station, York on 2 nd June 2011. An inquest was opened into her death by HM Coroner for the District of York, who conducted a number of pre-inquest hearings, in the course of which he heard submissions as to the scope of issues to be considered at the inquest. The coroner gave his ruling as to the scope of the inquest on 8 th June, 2015. The inquest was set for hearing on 9 th November 2015. On 3 rd November 2015 the court heard this rolled-up application for permission to apply and, if permission be granted, for judicial review of the coroner's decision as to the scope of the inquest. The application was brought by Ms Speck's mother, represented by Mr Swoboda. The defendant was the coroner, represented by Mr O'Brien QC. Two Interested Parties were represented before us: NHS England, represented by Mr Rawlinson; and MEDACS, represented by Ms Knight. A third Interested Party, the North Yorkshire Police, acknowledged service but had otherwise taken no part in the proceedings.
At the conclusion of the hearing, we refused permission, and reserved our reasons to be given in writing at a later date. These are my reasons for concluding that the application for permission must be refused.
It is sufficient for present purposes to summarise very briefly the circumstances in which the inquest was ordered.
Miss Speck was 31 years old at the date of her death. Sadly, she had a history of depression, bipolar affective disorder and drug use. She had, on a number of occasions, been admitted to Bootham Park Psychiatric Hospital in York. She had been discharged from her last such admission on 19 th April 2011. At 1450 on 2 nd June 2011, police officers on patrol in York were flagged down by a concerned member of the public. They found Miss Speck screaming and behaving erratically in the street. One of the officers detained her. He did so pursuant to his powers under section 136(1) of Mental Health Act 1983, which provides:
"If a constable finds in a place to which the public have access a person who appears to him to be suffering from mental disorder and to be in immediate need of care or control, the constable may, if he thinks it necessary to do so in the interests of that person or for the protection of other persons, remove that person to a place of safety within the meaning of section 135 above."
Section 135(6) (which has since 2011 been amended in respects which do not affect the issues in this case) defines a place of safety as
"… residential accommodation provided by a local services authority under Part 1 of the Care Act 2014 or Part III of the National Assistance Act 1948, a hospital as defined by this Act, a police station, an independent hospital or care home for mentally disordered persons or any other suitable place the occupier of which is willing temporarily to receive the patient."
Miss Speck was then taken to Fulford Road Police Station in York, where she was received into the custody suite at about 1500. She was agitated and violent. For her own safety she was searched and dressed in a safety suit. She was placed into a cell monitored by CCTV. At 1740, the Force Medical Examiner observed Miss Speck through the cell hatch, but did not enter the cell. He indicated that he would call the community care team. At 1752 it was seen that Miss Speck was perspiring profusely, and had removed some of her clothing. At 1800 she was seen to be slumped in a corner of the cell. Staff entered the cell and found her unresponsive. Attempts were made to resuscitate her, both at the police station and at the Accident and Emergency Department of York Hospital to which she was taken. They were unsuccessful, and at 1848 Miss Speck was pronounced dead.
The medical cause of Miss Speck's death was the subject of conflicting expert evidence from two consultant pathologists, and was one of the matters to be considered at the inquest. The written reports which were provided to this court showed that the opinion of one of the consultant pathologists was that Miss Speck died as a result of excited delirium, whilst the opinion of the other was that the cause of her death was serotonin syndrome.
Article 2 of the European Convention on Human Rights, incorporated into UK law by the Human Rights Act 1998, provides —
"1. Everyone's right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law.
2. Deprivation of life shall not be regarded as inflicted in contravention of this Article when it results from the use of force which is no more than absolutely necessary:
(a) in defence of any person from unlawful violence;
(b) in order to effect a lawful arrest or to prevent the escape of a person lawfully detained;
(c) in action lawfully taken for the purpose of quelling a riot or insurrection."
Given that Miss Speck died in police custody, it has throughout been common ground that article 2 is engaged, and that the inquest should be a "Middleton" or "article 2" inquest by which the state could discharge its procedural obligation under article 2 to investigate the death: see R (Middleton) v West Somerset Coroner [2004] UKHL 10, to which I refer further below.
Miss Speck's mother wished the inquest to consider a number of issues relating to the initial decision to take Miss Speck to a police station rather than a hospital. It would have been possible to take her directly to the Accident and Emergency ward of York Hospital. At the time, however, York did not have a specialist medical facility for persons detained under s136 of the Mental Health Act 1983. A decision has subsequently been made to establish such a facility, which for convenience will be referred to as a "health-based place of safety" or "HBPoS".
In relation to the scope of the inquest, Mr Swoboda, on behalf of the claimant, submitted that the inquest should consider, amongst other things, the detention of Miss Speck in police custody rather than at Bootham Hospital or another medical facility. He further submitted that the jury at the inquest should consider the following three questions in relation to Miss Speck's detention under the Mental Health Act:
"(a) Do you consider the Fulford Road Custody Suite an appropriate or inappropriate 'place of safety'?
(b) Do you consider there were suitable or unsuitable arrangements between the North Yorkshire and York Primary Care Trust [hereafter, "NYYPCT"] and North Yorkshire Police for 'places of safety'?
(c) Do you consider resources had been used appropriately or inappropriately by the North Yorkshire and York Primary Care Trust in the provision of 'places of safety'?"
In making those submissions, Mr Swoboda wished to persuade the coroner that the jury should consider how it had come about that, in 2011, York did not have a specialist medical facility which could be used as a place of safety for those detained under section 136 of the 1983 Act, and to consider what had become of funding which he said had been designated for, but not in fact spent on, the provision of such a HBPoS.
In his submissions on this issue on behalf of NHS England, Mr Rawlinson submitted that the state's procedural obligation to investigate did not extend to a consideration of the policy and funding considerations relevant to the provision of places of safety. He submitted that such matters involved political issues as to policy and resource allocation, and that investigation of them would improperly take the inquest into issues as to the state's substantive article 2 obligation to protect life. Moreover, he submitted, "such matters are far too remote to even begin to meet the test for causation in terms of factors that more than minimally, trivially or negligibly contributed to Miss Speck's death, with the proposed exploration of them straying so far beyond proper boundaries as to be wrong in law".
The coroner, having considered these competing submissions, gave the following ruling on 8 th June 2015:
"I have considered the various authorities referred to in all the submissions that I have received. Having done so, I am not satisfied that the threshold as expressed in R (Lewis) v HM Coroner for Mid and North Shropshire has been satisfied. Therefore the scope of the inquest will not include this issue. I adopt and accept the arguments put forward by NHS England/NYYPCT on this issue."
Later in his ruling the coroner indicated that the scope of the inquest would include Miss Speck's medical background, her arrest, her detention, the medical care provided during her detention and the cause of her death.
It is that ruling of 8 th June 2015 which was challenged in the present application for judicial review. Mr Swoboda submitted that the decision was unlawful because it was...
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