Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent)

Where an inquest is used to discharge the state's procedural obligation under article 2 of the European Convention on Human Rights, it should ordinarily culminate in an expression of the jury's conclusions on the disputed factual issues at the heart of the death.

For that purpose, “how” the deceased came by the death means both the means and the circumstances. The conclusion may take the form of an expanded short verdict, a narrative verdict or answers to factual questions. It may record acts and omissions, but must neither find a named person criminally liable nor appear to determine civil liability. Recommendations intended to prevent similar deaths remain the responsibility of the coroner.

A prisoner took his own life in his cell. A first inquest was quashed for insufficient inquiry. A second inquest thoroughly investigated the circumstances, but its formal verdict recorded only suicide while the balance of the deceased's mind was disturbed. The jury privately communicated concerns about failures by the Prison Service.

The deceased's mother sought judicial review so that the jury's conclusions would be recorded publicly. Stanley Burnton J declared in [2001] EWHC Admin 1043 that the restrictions upon the verdict made the inquest inadequate for the procedural requirements of article 2. The Court of Appeal, [2002] EWCA Civ 390, [2003] QB 581, substituted a declaration permitting a finding of systemic neglect where it could reduce the risk of repetition.

The Secretary of State appealed. The central questions concerned what an article 2 investigation must produce, whether the existing inquest regime met that requirement, and how the legislation and rules should be interpreted if it did not.

1. Appeal allowed to a limited extent. In a considered opinion agreed to unanimously, the Appellate Committee set aside the Court of Appeal's declaration. No replacement declaration was required because the investigation had been full and satisfactory, no further inquest was sought, and the jury's conclusions had become public.

2. The Committee held that the procedural obligation under article 2 of the European Convention on Human Rights requires an effective official investigation where a possible violation of the state's obligation to protect life appears to involve state agents or bodies. Where an inquest is the chosen mechanism, it ought ordinarily to culminate in an expression, however brief, of the jury's conclusions on the disputed factual issues at the heart of the case. An investigation which thoroughly gathers evidence may therefore remain insufficient if its formal outcome cannot communicate the conclusion on the central facts.

3. The existing regime could comply through the interpretative obligation in section 3 of the Human Rights Act 1998. “How” in section 11(5)(b)(ii) of the Coroners Act 1988 and rule 36(1)(b) of the Coroners Rules 1984 means not merely “by what means”, but “by what means and in what circumstances”. The narrower approach in R v HM Coroner for North Humberside and Scunthorpe, Ex p Jamieson [1995] QB 1 could not govern an article 2 inquest to that extent.

4. The coroner has discretion to elicit the necessary conclusions through an expanded short-form verdict, a brief narrative verdict, or answers to factual questions. Interested parties may make submissions about the proposed means and questions. A court should not disturb the coroner's choice unless strong grounds are shown.

5. Rules 36(2) and 42 remain effective constraints. A jury may state factual and judgmental conclusions about acts or omissions, but may not find a named person criminally liable or appear to determine civil liability. Expressions suggestive of civil liability, including “carelessness” and the technical inquest term “neglect”, should be avoided. The distinction adopted by the Court of Appeal between individual and systemic neglect was unsatisfactory because the categories overlap and either kind of failure may require identification.

6. Recommendations for preventing recurrence remain for the coroner under rule 43, not the jury. Ordinarily, article 2 will be most effectively discharged if the coroner publicly announces both an intention to report and the neutrally expressed substance of the proposed report. In the absence of full criminal proceedings, and unless informed otherwise, a coroner should assume that the inquest is the process by which the state will discharge its investigative obligation.

1. House of Lords: The Secretary of State's appeal was allowed to the extent that the Court of Appeal's declaration was set aside. No replacement declaration or order for costs was made. The considered opinion was agreed to unanimously.
2. Court of Appeal: In [2002] EWCA Civ 390 , [2003] QB 581 , the court set aside the Administrative Court's declaration and substituted a declaration permitting a finding of neglect where an inquest discharged the article 2 obligation and the finding could reduce the risk of repetition.
3. Administrative Court: In [2001] EWHC Admin 1043, Stanley Burnton J refused to order incorporation of the jury's private note but declared that restrictions on the verdict rendered the inquest inadequate to meet article 2.
4. Inquests: The first verdict was quashed for insufficient inquiry. A second inquest investigated the death fully but did not publish the jury's conclusions about failures by the Prison Service.