Sacker v HM Coroner for the County of West Yorkshire

Where Article 2 requires an effective investigation into a death in custody, a coroner should permit the jury to add a rider of systemic neglect if such a finding could reduce the risk of similar deaths. A neglect finding also requires a clear and direct causal connection between the conduct and the death.

A report intended to prevent future fatalities under rule 43 of the Coroners Rules 1984 does not necessarily discharge the Article 2 obligation. If the omission of a neglect direction creates a real possibility of a different verdict, the inquisition may be quashed and a fresh inquest ordered.

The appellant’s daughter took her own life while held on remand in prison. A self-harm risk form had been opened, but a locum doctor did not understand its procedures and the required case review was not undertaken. The coroner permitted several possible verdicts but did not allow the jury to add a rider that neglect had contributed to the death. He subsequently reported his concerns to the Prison Service under rule 43 of the Coroners Rules 1984.

Tucker J refused permission to seek judicial review because of delay and on the merits. The appellant sought an extension of time, permission to appeal and judicial review. The central issue was whether, following Middleton [2002] EWCA Civ 390, the jury should have been permitted to consider a systemic-neglect rider.

1. Appeal allowed. Pill LJ, with whom Mummery and Latham LJJ agreed, held that the inquisition should be quashed and a fresh inquest ordered.

2. The approach in Middleton [2002] EWCA Civ 390 applied to a challenge concerning the absence of an opportunity to add a neglect rider to a suicide verdict. When necessary to vindicate Article 2, a coroner may permit a jury to identify systemic neglect, notwithstanding the restrictions imposed by rule 42 of the Coroners Rules 1984. The relevant question is whether a jury finding on neglect could help to reduce the risk that the circumstances causing the death would recur.

3. The prison’s self-harm procedure required a case review no later than the deceased’s discharge from the healthcare centre. The procedure had not been followed, and there was evidence that the locum doctor did not understand the system. The coroner’s own rule 43 report demonstrated both his grave concern and his view that preventative action was required.

4. A neglect rider required the clear and direct causal connection described in Jamieson [1995] QB 1. That connection could not be excluded. Had the prescribed procedure been followed, measures might have been taken which arguably would have prevented the death. There was consequently a real possibility of a different verdict.

5. The coroner’s action under rule 43 did not, in these circumstances, satisfy Article 2. Pill LJ nevertheless expressed reservations about using neglect riders to vindicate Article 2. He considered that the restricted procedures at inquests might make them ill-equipped to investigate and particularise systemic neglect, and that preventative reporting under rule 43 could sometimes be more effective.

6. The time for seeking judicial review was extended. Time spent obtaining public funding was relevant to that discretion. The advisers had acted promptly and could not fairly be criticised for failing to anticipate Middleton; the issue was of considerable public importance; and reopening it was not detrimental to good administration.

1. Court of Appeal (Civil Division): Granted an extension of time and permission to appeal, allowed the appeal, quashed the inquisition and ordered a fresh inquest: [2003] EWCA Civ 217.
2. Administrative Court: Tucker J refused permission to apply for judicial review on 4 July 2002, both for lack of promptness and on the merits.
3. Coroner’s inquest: On 12 October 2001 the jury returned a majority conclusion that the deceased had killed herself. The coroner had declined to permit a rider that neglect contributed to the death.