Regina v. Her Majesty's Coroner for the County of West Yorkshire (Appellant) ex parte Sacker (FC) (Respondent)

Where article 2 requires an effective investigation into a death, the statutory question how the deceased came by the death extends beyond the immediate means of death. By section 3 of the Human Rights Act 1998, it means by what means and in what circumstances the death occurred.

An inquest into a custodial suicide must be capable of examining systemic and operational failures, identifying the causes of the suicide, and considering omitted preventive steps and precautions for avoiding similar deaths. An inquest confined to the former test of gross neglect directly connected with the suicide does not satisfy that obligation.

The respondent's daughter killed herself while remanded in custody. Evidence disclosed possible failures in risk assessment, communication, staff understanding of suicide-prevention procedures, cell allocation and emergency response. Following the guidance then given by R v Coroner for North Humberside and Scunthorpe, Ex p Jamieson [1995] QB 1, the coroner declined to permit a rider that neglect had contributed to the death.

Sir Richard Tucker refused permission to apply for judicial review. The Court of Appeal, Pill, Mummery and Latham LJJ, allowed the respondent's appeal, quashed the inquisition and ordered a fresh inquest: [2003] EWCA Civ 217.

The coroner appealed. The central issue was whether the jury should have been permitted to consider whether systemic neglect contributed to the death, given the investigative obligation under article 2 of the Convention.

1. Appeal dismissed unanimously. The Appellate Committee delivered a considered opinion agreed by Lord Bingham of Cornhill, Lord Hope of Craighead, Lord Walker of Gestingthorpe, Baroness Hale of Richmond and Lord Carswell. The Court of Appeal's order quashing the inquisition and directing a fresh inquest was upheld.

2. The Committee held that the coroner's original ruling could not be criticised by reference to the law as it was then understood. It accorded with R v Coroner for North Humberside and Scunthorpe, Ex p Jamieson [1995] QB 1, under which “how” meant the means by which death occurred and a neglect rider required gross neglect directly connected with the suicide.

3. Applying the companion decision in R v HM Coroner for the Western District of Somerset, Ex p Middleton [2004] UKHL 10, the Committee held that this narrow construction could no longer govern an inquest required to satisfy article 2. Section 3 of the Human Rights Act 1998 required “how” in section 11(5)(b)(ii) of the Coroners Act 1988 and rule 36(1)(b) of the Coroners Rules 1984 to mean by what means and in what circumstances the deceased came by the death. The statutory scheme otherwise remained controlling, and the coroner retained the discretion described in Middleton.

4. The original inquest could not investigate the wider circumstances in that manner. It therefore could not address the State's positive article 2 obligation to take effective operational measures to safeguard life. In particular, it could not identify the causes of the suicide, preventive steps which could have been taken, or precautions needed to reduce the risk to other prisoners.

5. The evidence disclosed matters capable of supporting inquiry into systemic or operational failure, including inadequate communication, unfamiliarity with suicide-prevention procedures, isolation in a single cell, access to material usable as a ligature and reliance on half-hourly observations. Whether those matters were causally connected with the death was for the fresh inquest.

6. The Committee left undecided whether article 2 applied on the basis of an ongoing breach where the death preceded the commencement of the relevant provisions of the Human Rights Act 1998, although the inquest occurred afterwards. That contention had not been challenged in the proceedings.

1. House of Lords: The coroner's appeal was dismissed unanimously. The order for a fresh inquest was upheld: [2004] UKHL 11.
2. Court of Appeal: Pill, Mummery and Latham LJJ allowed the respondent's appeal, quashed the inquisition and ordered a fresh inquest: [2003] EWCA Civ 217.
3. High Court: Sir Richard Tucker refused the respondent permission to apply for judicial review.