Davies, R (on the application of) v HM Deputy Coroner for Birmingham

Where a death in custody requires the state to discharge its procedural duty under Article 2, the inquest must provide a full and effective public inquiry. If the evidence permits, the jury must be able to consider whether systemic neglect contributed to the death.

A verdict identifying systemic neglect may be returned without determining civil liability, provided no individual is named. A coroner’s Rule 43 letter is not an adequate substitute where such a verdict is available. A clinical judgment, or some medical action, does not necessarily preclude neglect. The issue remains whether there was a gross failure to provide basic medical attention, with a clear and direct causal connection to death.

The claimant was the mother of a prisoner who died after repeated vomiting and apparent drug-withdrawal symptoms. A coroner’s jury returned a verdict of accidental death following an inquest into his death at HMP Birmingham.

Moses J dismissed the claimant’s judicial-review challenge. Although he found material defects in the coroner’s directions on neglect and systemic failure, he declined to quash the inquisition because of the extensive evidence heard and recommendations subsequently made to the prison.

The appeal concerned whether those defects, including the exclusion of parts of an independent medical report, required a fresh inquest in order to meet the procedural requirements of Article 2 of the European Convention on Human Rights.

1. Appeal allowed unanimously. Brooke LJ gave the leading judgment. Longmore LJ agreed and additionally held that the coroner had wrongly excluded relevant parts of Dr Ralli’s evidence. Sir Martin Nourse agreed with both judgments.

2. The inquest had failed to give the jury a proper opportunity to consider whether systemic defects in the prison’s medical-care arrangements amounted to neglect contributing to the death. It had also failed clearly to explain that a nurse’s clinical judgment, including a decision not to obtain assistance, could itself constitute neglect if it amounted to a gross failure to provide basic medical attention.

3. The court applied the approach in [2002] EWCA Civ 390 and the House of Lords’ decision in [2003] UKHL 51. Where an inquest is realistically the only process by which the state can discharge its Article 2 procedural obligation, it must provide a full and effective public investigation. A jury may return a verdict incorporating systemic neglect in a broader range of circumstances than the ordinary Jamieson approach contemplated, provided that no individual is named. Such a finding does not determine civil liability and is permissible notwithstanding Rule 42 of the Coroners Rules 1984.

4. A Rule 43 letter and post-inquest recommendations could not substitute for a jury verdict where neglect was properly available on the evidence. The prior inquest therefore did not satisfy the Article 2 obligation. The extensive evidence previously heard did not remove the need for an effective public determination of the central systemic issue.

5. The inquisition was quashed. Unless an inquiry under section 17A of the Coroners Act 1988 was established with equivalent function and more appropriate powers, the coroner was required to hold a new inquest under section 8(1)(c). Its primary scope was whether systemic neglect was a contributory cause of death.

• Court of Appeal (Civil Division): Allowed the appeal, quashed the inquisition, and directed a new inquest unless an equivalent inquiry under section 17A of the Coroners Act 1988 was established: [2003] EWCA Civ 1739.
• Administrative Court: Moses J dismissed the judicial-review application on 11 February 2003. He found deficiencies in the coroner’s directions but held that it was not necessary or desirable to quash the verdict or order a fresh inquest.