R (Middleton) v West Somerset Coroner

This case concerns the procedural obligation under Article 2 of the European Convention on Human Rights to carry out an effective public investigation into deaths where the State's substantive Article 2 obligations may have been violated. The House held that an inquest ordinarily must be capable of culminating in an expression by the jury, however brief, of its conclusions on the disputed factual issues central to the death.

The court identified the relevant statutory instruments (the Coroners Act 1988 and the Coroners Rules 1984) and concluded that only a change of interpretative approach was required to secure Convention compliance: the word "how" in section 11(5)(b)(ii) of the Coroners Act 1988 and rule 36(1)(b) of the Coroners Rules 1984 should be read broadly to mean "by what means and in what circumstances" so that, in appropriate cases, a jury may be invited to return a narrative verdict or answers to factual questions without naming individuals or determining civil or criminal liability. The coroner retains responsibility for making prevention reports under rule 43.

This was an appeal from a Court of Appeal declaration concerning an inquest into the suicide, in prison, of Colin Campbell Middleton. The applicant (the deceased's mother) sought a public recording of a jury note which had expressed concern about the Prison Service's care; the coroner declined to append the jury's private note to the inquisition. At first instance Stanley Burnton J concluded that in some cases a formal public finding of neglect may be necessary to satisfy Article 2 but refused the order to incorporate the jury's note because of how it had been produced. The Court of Appeal allowed in part and made a declaration that rule 42 could be construed to permit a finding of neglect (so long as no individual was named) in appropriate cases. The Secretary of State appealed to the House of Lords.

Nature of the claim/application: judicial review of the coroner's refusal to record and publish the jury's note and a declaration as to the compatibility of inquest procedure with Article 2 ECHR.

Issues framed by the court:

• What the Article 2 procedural obligation requires of a properly conducted official investigation into a death potentially involving a State failure;
• Whether the existing inquest regime under the Coroners Act 1988 and Coroners Rules 1984 meets that obligation;
• If not, whether and how the inquest regime can be interpreted or adapted to meet Article 2.

Reasoning and disposition: the House surveyed European Court of Human Rights authorities (including McCann, Jordan and Keenan) and concluded that Article 2 requires that, in cases where the Article 2 obligation arises, an investigation must be effective and ordinarily culminate in an expression of the fact-finding body's conclusions on the core disputed factual issues. The court held that the coroner's regime can meet Article 2 if the statutory provisions and rules are interpreted to allow, in appropriate cases, a narrative verdict or answers to factual questions enabling the jury to state factual conclusions without attributing criminal or civil liability or naming individuals. The House therefore set aside the Court of Appeal's broader declaration, but rejected the use of private jury notes and endorsed the coroner's continuing role in making prevention reports under rule 43. The appeal of the Secretary of State succeeded in part and the Court of Appeal's declaration was set aside.

Appeal allowed in part. The House held that Article 2 requires that, where it applies, an inquest should ordinarily be able to culminate in an expression by the jury of its factual conclusions on the central disputed issues. To secure compliance it is sufficient to adopt a broader interpretation of "how" in section 11(5)(b)(ii) of the Coroners Act 1988 and rule 36(1)(b) of the Coroners Rules 1984 so as to permit, in appropriate cases, a narrative verdict or factual questions. The Court of Appeal's declaration was set aside to the extent it required a different remedy; private jury notes should not be appended to the inquisition and the coroner remains responsible for reporting preventive measures under rule 43.

High Court (Administrative Court): Stanley Burnton J, [2001] EWHC Admin 1043 (judgment dated 14 December 2001) — declaration that the inquest was inadequate to meet Article 2; Court of Appeal: [2002] EWCA Civ 390, [2003] QB 581 — set aside judge's declaration and issued a declaration about construing rule 42; House of Lords (Appellate Committee): [2004] UKHL 10 (this judgment).