Plymouth City Council v HM Coroner County of Devon (Plymouth & South West District) & Anor

Article 2’s investigative duty arises only where there is at least an arguable breach of the State’s protective duty. For a child living with a parent in the community, the relevant question is whether the authorities knew or ought to have known of a real and immediate risk to life and failed to take measures which might reasonably have been expected to avoid it. General vulnerability, neglect concerns, missed appointments and hindsight do not themselves satisfy that threshold. Where the evidence does not arguably establish that risk, a coroner has no Article 2 duty to conduct a broadened inquest into the role of child-protection agencies. The court also indicated that a Part 8 review might assist in discharging an investigative duty, but its adequacy remained unresolved.

Plymouth City Council sought judicial review of the coroner’s decision concerning the inquest into the death of Perrin, a nine-month-old child who died from bronchopneumonia after severe dehydration. The coroner decided that the inquest should examine whether Plymouth and other statutory child-protection agencies had contributed to the death.

He considered that Article 2 of the Convention imposed an investigative duty because the agencies might have failed to protect Perrin’s life, and that existing criminal, family and administrative investigations did not discharge that duty. The central issue was whether the evidence arguably showed that the agencies knew or ought to have known of a real and immediate risk to Perrin’s life.

1. Judicial review allowed. The coroner’s first determination was quashed. On the available evidence, the Article 2 investigative duty was not engaged, and the coroner’s court was not required to conduct the proposed broadened inquest.
2. Article 2 imposes a protective duty and a collateral investigative duty. The investigative duty may arise where death has been caused or contributed to by a breach of domestic law protecting life or by an arguable breach of the protective duty. It is not confined to cases where a breach of the protective duty is ultimately established.
3. For a child living with a parent in the community, the protective-duty threshold follows Osman v UK [1999] 1 FLR 193. The authorities must have known, or ought to have known, of a real and immediate risk to the life of an identified individual and must have failed to take measures within their powers which, judged reasonably, might have been expected to avoid that risk.
4. The coroner correctly stated that test but misapplied it. Perrin’s vulnerability, poor weight gain, missed appointments, the family’s history and the agencies’ extensive concerns did not establish an arguable risk to his life of the required quality. His death resulted from severe dehydration and bronchopneumonia during the final two days, and there was no sufficient earlier indication that his life was at real and immediate risk.
5. The court’s observations on the possible adequacy of care proceedings, criminal proceedings and a Part 8 review were academic. A Part 8 review might have features suitable for an Article 2 investigation, but its focus on inter-agency learning rather than breach of the protective duty created an unresolved difficulty.
6. There was no order as to costs. Although the coroner’s participation was not wholly neutral, it was low-key, constructive and materially assisted the court. Permission to appeal against the costs decision was refused.

This was a first-instance judicial review of the coroner’s ruling. The court quashed the determination that Article 2 was engaged and that the coroner’s court should investigate the role of the child-protection agencies.