Commissioner of Police for the Metropolis, R (on the application of) v Coroner Southern District of Greater London & Ors

At an inquest, a verdict involving neglect may be left to the jury only where the evidence, taken at its highest, could support the essential elements of neglect: an apparent need for care, a gross failure to provide it, and a clear and direct causal connection with the death. Neglect is distinct from civil negligence and must contribute more than trivially, although it need not be the sole cause. R v HM Coroner for North Humberside and Scunthorpe ex parte Jamieson continues generally to apply, subject to the limited Article 2 qualification identified in R (Amin) v Secretary of State for the Home Department; R (Middleton) v West Somerset Coroner. A single clinical error does not itself establish system neglect. On the evidence, no neglect verdict was properly open and the reference to system neglect was quashed.

Scott Robbins died by suicide while detained at Croydon Police Station. At the inquest, the coroner ruled that the evidence was sufficient to leave neglect to the jury, distinguishing between individual neglect and system neglect. The jury returned a majority verdict that Mr Robbins had killed himself, contributed to by system neglect.

The Commissioner sought judicial review and an order quashing that part of the inquisition. The challenge concerned whether the evidence could lawfully support leaving any neglect verdict to the jury, particularly in circumstances where the evidence included a previous episode of self-harm, limited police training and medical examinations which found no continuing risk.

1. Claim allowed in part and verdict quashed. The words “contributed to by system neglect” were quashed. A fresh inquest was unnecessary, and there was no order as to costs.
2. The sufficiency of evidence to support a possible verdict is a question of law for the coroner. A subsequent jury verdict cannot cure an evidential insufficiency. The coroner must nevertheless leave genuinely borderline questions to the jury, bearing in mind the jury’s role on weight, credibility, value judgment and causation.
3. The applicable framework was drawn from R v HM Coroner for North Humberside and Scunthorpe ex parte Jamieson. Neglect in the coronial sense is not civil negligence. It requires a gross failure to provide or procure basic care for a person in a dependent position who cannot provide it for himself. Where suicide is established, neglect may contribute only where gross neglect is directly connected with the suicide. The causal contribution need not be sole or predominant, but must be more than minimal, negligible or trivial.
4. R (Amin) v Secretary of State for the Home Department; R (Middleton) v West Somerset Coroner did not generally overrule ex parte Jamieson. It permitted a neglect finding, where necessary to vindicate Article 2, in the particular circumstances of an inquest where identifying a system defect could reduce the risk of repetition. It did not establish that individual failings and system defects were separate alternative verdicts, nor that the evidential threshold was otherwise displaced.
5. The evidence did not show that the police or medical officers knew or ought to have known of a real and immediate risk of suicide. The previous self-harm episode had led to medical assessment, and subsequent observations disclosed no continuing risk. Lack of training, the cell fitting and the medical examinations did not, individually or cumulatively, establish a gross system failure or a causal link with the death. The court therefore held that no neglect verdict, whether individual or systemic, could properly have been left to the jury.

The judgment itself records that the coroner’s ruling and the jury’s verdict were challenged by judicial review. Permission was granted by Pitchford J on 21 February 2003. The Administrative Court allowed the claim to the extent of quashing the reference to system neglect.