Sacker, R (on the application of) v Coroner for the County of West Yorkshire

The Appellate Committee held that, in the light of the Human Rights Act 1998 and article 2 of the European Convention on Human Rights, the statutory words directing the scope of an inquest (in particular section 11(5)(b)(ii) of the Coroners Act 1988 and rule 36(1)(b) of the Coroners Rules 1984) must be given a broader meaning so that an inquest can inquire not only "by what means" but "by what means and in what circumstances" a death occurred.

On the facts of this case the coroner’s refusal to invite the jury to consider a rider that the deceased's suicide was "contributed to by neglect" deprived the inquest of the ability to subject the death in custody to adequate public scrutiny under article 2 and to identify any systemic operational failures and measures to prevent recurrence. That deficiency made a fresh inquest appropriate.

Background and parties: The respondent, the mother of Sheena Creamer, sought judicial review of the coroner's conduct of an inquest into her daughter's death in custody. Ms Creamer died on 7 August 2000 while remanded at HM Prison New Hall. A jury at the inquest returned a majority verdict that she had killed herself. The respondent had asked that the jury be permitted to add the words "contributed to by neglect" to their verdict; the coroner declined to give that opportunity.

Procedural history: Permission to apply for judicial review was refused by Sir Richard Tucker (4 July 2002). The Court of Appeal allowed the respondent's appeal, quashed the inquisition and ordered a fresh inquest ([2003] EWCA Civ 217). The coroner appealed to the House of Lords.

Nature of the claim and relief sought: The respondent sought review of the coroner's refusal to permit the jury to add a rider indicating that neglect contributed to the suicide; the practical relief sought (and later ordered by the Court of Appeal) was a quashing of the inquisition and the holding of a fresh inquest so that the jury could consider whether systemic neglect had contributed to the death.

Issues for decision: (i) Whether the coroner should have invited the jury to consider adding a rider that systemic neglect contributed to the suicide; (ii) how the statutory phrase "how" in section 11(5)(b)(ii) of the Coroners Act 1988 and rule 36(1)(b) should be interpreted in the light of the Human Rights Act 1998 and article 2 ECHR; (iii) whether the existing inquest deprived the public and the family of the inquiry necessary to satisfy the State's article 2 positive obligations in deaths in custody.

Court's reasoning: The Committee accepted that the scheme for inquests enacted by Parliament must generally be respected but that, under section 3 of the Human Rights Act 1998, a narrower construction should be adjusted where necessary to comply with the Convention. Following the approach explained in R v HM Coroner for the Western District of Somerset, Ex p Middleton ([2004] UKHL 10), the word "how" in the relevant provisions is properly given a broader meaning to permit consideration of the circumstances and systemic factors leading to death. The coroner's refusal to invite the jury to consider whether neglect contributed to death meant the inquest could not adequately investigate whether operational measures had been taken or omitted by the State to protect life, as required by article 2 and the authorities (notably Osman). Given that deficiency, a fresh inquest was the appropriate remedy.

Subsidiary observations: The coroner had properly used rule 43 to report concerns about the locum medical officer's lack of familiarity with form F2052SH procedures. The Committee noted that the death occurred before the Human Rights Act came into force but the inquest took place after that date; no decision was made on the respondent's alternative submission of an ongoing article 2 breach.

Appeal dismissed. The House of Lords held that, in light of the Human Rights Act 1998 and article 2 ECHR, the statutory scope of inquests (section 11(5)(b)(ii) Coroners Act 1988 and rule 36(1)(b) Coroners Rules 1984) must be given a broader meaning so that systemic operational failures contributing to a death in custody can be investigated; the coroner should have afforded the jury the opportunity to consider a rider that neglect contributed to the suicide, and the appropriate remedy was a fresh inquest.

Permission to apply for judicial review refused by Sir Richard Tucker (4 July 2002). Court of Appeal allowed the respondent's appeal, quashed the inquisition and ordered a fresh inquest ([2003] EWCA Civ 217). Appeal to the House of Lords dismissed ([2004] UKHL 11).