Goodson v HM Coroner for Bedfordshire & Luton

Simple negligence in hospital treatment which causes death does not, without more, breach the state’s substantive obligation to protect life under article 2 of the European Convention on Human Rights. A separate procedural duty to investigate arises only exceptionally, where the circumstances suggest a possible breach of that substantive obligation.

An article 2 investigation must satisfy minimum standards, but their application depends on context. An inquest into a hospital death does not invariably require independent medical evidence. Its absence concerns the investigation’s effectiveness, rather than the coroner’s independence, and must be assessed in light of the evidence, issues and coroner’s expertise.

An 83-year-old patient died in an NHS hospital after an elective procedure caused perforations, peritonitis and cardiac arrest. The coroner conducted an inquest, declined to obtain an independent medical report and recorded death by misadventure.

The deceased’s daughter sought judicial review and an order quashing the verdict. She contended that article 2 of the European Convention on Human Rights required an independent and effective investigation, including independent expert evidence. Alternatively, she argued that proceeding without such evidence was unlawful under ordinary coronial principles.

The issues were whether the article 2 investigative obligation was engaged, whether the inquest satisfied it if engaged, and whether the coroner’s decision was otherwise lawful.

1. The claim was dismissed. The procedural obligation to investigate under article 2 of the European Convention on Human Rights was not engaged. A patient in an NHS hospital was in the care of the state, but the material disclosed at most a possibility of simple negligence. Simple negligence in medical care does not itself breach the state’s positive obligation to protect life. A separate procedural obligation arises only in exceptional hospital cases where the circumstances indicate a possible breach of that positive obligation.

2. The state’s obligation in ordinary medical-negligence cases is to provide an effective judicial system capable of establishing the cause of death and any professional liability. The available criminal, civil and disciplinary procedures must be considered together. An inquest forms only part of that system and cannot be impugned merely because it does not alone provide the totality of the required investigation.

3. Even if the procedural obligation had applied, the inquest satisfied article 2. Every article 2 investigation must meet minimum standards, including independence and effectiveness, but those standards permit contextual flexibility. A hospital death involving possible negligence need not receive the same form or intensity of investigation as an intentional killing or death in custody.

4. The inquest was independent because the coroner was independent. The absence of an independent medical expert concerned effectiveness, not independence. Independent expert evidence is not invariably required. The question depends on the coroner’s expertise, the issues and the evidence available.

5. The coroner had the clinical records, post-mortem evidence, statistical material and evidence from two experienced clinicians. Their evidence was tested by cross-examination, and no contrary expert evidence had been placed before him. The inquest was therefore effective despite the absence of an independent expert.

6. When determining article 2 effectiveness, the court forms its own judgment while allowing appropriate deference to the experienced coroner who heard the evidence. Outside article 2, the decision not to investigate further was reviewable on Wednesbury principles and was plainly reasonable. Permission to seek judicial review was granted, but the substantive claim was dismissed.

• High Court (Administrative Court): Permission to seek judicial review was granted, but the substantive challenge to the coroner’s decisions and inquest verdict was dismissed: [2004] EWHC 2931 (Admin) .
• Coroner’s inquest: The coroner refused requests to conduct an article 2 investigation and obtain independent medical evidence. He recorded a verdict of death by misadventure.