Sacker v HM Coroner for the County of West Yorkshire

The Court of Appeal allowed an appeal against the refusal of permission to apply for judicial review of a coroner's decision not to give a jury the opportunity to add a rider that "neglect had contributed" to a death in custody. The court applied the approach in Middleton [2002] EWCA Civ 390 and held that, where Article 2 of the European Convention on Human Rights may require it, a coroner should, in appropriate cases, permit a jury to make a finding identifying systemic neglect without naming individuals, consistent with Rules 36, 42 and 43 of the Coroners Rules 1984 and section 6 of the Human Rights Act 1998.

The court analysed the F2052SH self-harm procedure, found that the procedure was not followed, and concluded that there was evidence of system neglect and a sufficient causal connection between the alleged failures and the death to make leaving a neglect rider to the jury appropriate. The inquisition was quashed and a fresh inquest ordered.

Background and procedural posture. This was an application for permission to appeal against Tucker J's order of 4 July 2002 refusing permission to apply for judicial review of the coroner's decision (11 October 2001) declining to leave to a coroner's jury the opportunity to return a verdict including a rider that "neglect had contributed" to the suicide of Sheena Creamer, a remand prisoner who died on 7 August 2000. The appellant is the deceased's mother and sought to quash the inquisition and obtain a fresh inquest.

Facts. The deceased was placed on an F2052SH self-harm form on 4 August 2000, admitted briefly to the health care centre and returned to a single cell on 5 August. The locum doctor who examined her recorded that she was not suicidal and recommended return to the residential unit. No case review or support plan recorded under the F2052SH procedure was evident. The deceased was found hanging on the night of 6–7 August and pronounced dead.

Nature of the application. (i) The appellant sought permission to appeal and, if granted, permission to apply for judicial review to quash the inquisition and order a fresh inquest. (ii) The principal legal issue was whether, in the light of Article 2 ECHR and the Court of Appeal's decision in Middleton, the coroner ought to have allowed the jury the opportunity to add a rider identifying systemic neglect as contributing to the death. Secondary issues included whether there was a clear and direct causal connection between the alleged neglect and the cause of death, and whether delay should prevent the application.

Court's reasoning. (iii) The court analysed the F2052SH form and procedures and found that the prescribed case review and support-plan steps were not followed and that the coroner's Rule 43 letter evidenced concern about the locum doctor's lack of understanding of the procedure. Applying Middleton's interpretation of Article 2 obligations, the court concluded that where a finding of system neglect could reduce the risk of recurrence and a causal link is established, a coroner should permit the jury to make such a finding without identifying individuals (so as not to offend Rule 42). The court found the causal link sufficiently arguable here and that the failure to give the jury the opportunity for a neglect rider was a defect requiring quashing of the inquisition. The court also exercised its discretion to extend time for the application because of the applicant's attempts to obtain public funding and other factors, relying on Jackson.

Wider comments. The court expressed reservations about the suitability of inquests as the forum for identifying systemic neglect but accepted that Middleton binds the court and that Rule 43 correspondence does not, on its own, discharge Article 2 obligations in such circumstances.

Appeal allowed. The Court of Appeal held that, applying Middleton and Article 2 ECHR, the coroner should have given the jury the opportunity to add a rider identifying systemic neglect contributing to the death where there was evidence of system failures and a real possibility of a causal connection. The failure to give that opportunity was a defect which required the inquisition to be quashed and a fresh inquest ordered. The court also allowed an extension of time for permission to apply for judicial review, taking into account the applicant's pursuit of public funding and other factors.

On appeal from the Queen's Bench Division, Administrative Court (Tucker J), which on 4 July 2002 refused permission to apply for judicial review. The Court of Appeal granted an extension of time, gave permission to appeal and allowed the appeal, quashing the inquisition and ordering a fresh inquest.