Pearson v HM Coroner for Inner London North

The Human Rights Act 1998 does not require an Article 2-compliant inquest into a death occurring before the Act came into force. The procedural obligation to investigate a death is consequential upon the substantive obligation to protect life and cannot apply domestically where that substantive obligation was not engaged.

For such an inquest, Jamieson remains applicable. The question how the deceased came by his death means by what means, directed towards matters directly causative of death. The coroner controls the scope of the inquiry and need not investigate remote underlying circumstances.

The claimant, the mother of Kelly Pearson, applied under section 13 of the Coroners Act 1988 for a fresh inquest. Kelly died in November 1999 after being mistakenly detained in London on an executed warrant and later released. The inquest, held in 2002, recorded death from drug poisoning and returned a verdict of misadventure.

The claimant alleged insufficiency of inquiry. She argued that the coroner should have conducted an Article 2-compliant inquest under Regina (Middleton) v West Somerset Coroner and Regina (Sacker) v West Yorkshire Coroner, or, alternatively, that the inquest failed to satisfy Regina v North Humberside Coroner, ex parte Jamieson.

1. Retrospectivity. The claim was dismissed. The Human Rights Act 1998 did not require the 2002 inquest to comply with the wider Article 2 approach because Kelly’s death occurred before 2 October 2000.
2. Article 2 obligation. The procedural duty to conduct an effective investigation is consequential, secondary and ancillary to the substantive duty to protect life. Following In re McKerr, if the substantive Article 2 obligation did not arise domestically in respect of the earlier death, the consequential investigative obligation could not arise after commencement of the Act. The suggested continuing breach did not alter that conclusion.
3. Relationship with earlier decisions. The point had been left open in Regina (Middleton) v West Somerset Coroner and Regina (Sacker) v West Yorkshire Coroner. Their wider interpretation of “how” therefore did not govern this case. The possibility of international proceedings in Strasbourg did not assist the claimant domestically. The different context in Wilson v First County Trust Ltd (No 2) did not justify retrospectivity here.
4. Scope of the inquest. Under section 11(5)(b)(ii) of the Coroners Act 1988 and rule 36 of the Coroners Rules 1984, the pre-Article 2 meaning of “how” was “by what means”. Applying Regina v North Humberside Coroner, ex parte Jamieson and Regina v Inner West London Coroner, ex parte Dallaglio, the coroner was required to investigate relevant facts fully, fairly and fearlessly, but retained control over the boundaries of the inquiry and could exclude matters too remote from the death.
5. The evidence concerning the final two days, including the detention, court appearance, medical condition and treatment, was considerable. The coroner was entitled to regard a detailed inquiry into the mistaken warrant and related underlying events as unnecessary under the applicable law. There had therefore been no insufficiency of inquiry.

First-instance judicial review proceedings under section 13 of the Coroners Act 1988. The High Court dismissed the claim.