Pekkelo, R (on the application of) v HM Coroner for Central & South East Kent

A finding of neglect at an inquest requires a gross failure to provide basic medical attention to a dependent person, together with a clear and direct causal connection between that failure and the death. The test must be considered as a whole, including how the person’s condition objectively appeared and whether medical attention was obviously required.

Article 2’s investigative obligation does not invariably require a narrative verdict. A coroner has discretion to choose how best to elicit the jury’s conclusions. A traditional short-form verdict may suffice where the evidence has fully exposed the relevant facts and circumstances.

Mrs Ozmico died after developing a severe infection while detained by immigration authorities. An inquest jury returned a verdict of natural causes and declined to add that the death was due to neglect.

The claimant, Mrs Ozmico’s husband, sought judicial review of the coroner’s directions and his decision not to require the jury to answer proposed questions or return a narrative verdict. The issues were whether the direction on neglect misstated the legal test and whether the inquest failed to satisfy the investigative obligation under article 2 of the European Convention.

1. Application dismissed. The coroner had not erred in law in directing the jury on neglect.
2. Under R v Coroner for North Humberside and Scunthorpe ex parte Jamieson [1995] QB 1, neglect requires a gross failure to provide or procure basic medical attention for a dependent person, and a clear and direct causal connection between the conduct and the death. The test must be read as a whole. The crucial question includes how the person’s physical or mental condition appeared.
3. The coroner’s reference to the objective apparent seriousness of Mrs Ozmico’s condition did not introduce an impermissible subjective or foreseeability test. The jury had been told that the immigration authorities recognised by about 10 am that she needed medical attention. They had also been reminded of the conflicting medical evidence on causation. The jury were entitled to conclude that the delay had not caused the death.
4. Article 2 imposed an investigative obligation because Mrs Ozmico had been detained by, or under the control of, the State. The inquest satisfied that obligation. Relevant witnesses gave evidence, the disputed events were explored, and the Immigration Service’s critical investigation report was available and examined.
5. R (on the application of Amin) v Secretary of State for the Home Department [2004] 1 AC 653 and R (Middleton) v Coroner for the Western District of Somerset [2004] 2 AC 182 did not require a narrative verdict in every case. As explained in Middleton, the coroner has discretion to select the means of eliciting the jury’s conclusions. A traditional short-form verdict may be sufficient where it adequately addresses the circumstances of death. The jury’s verdict showed that it considered the failures of care immaterial to the cause of death.

The judgment records that permission to bring the judicial review claim was granted by Calvert-Smith J on 20 October 2005. No prior merits decision is stated.