Allen, R (on the application of) v HM Coroner for Inner North London

Article 2 investigative obligations are engaged where fundamental systemic failures cause death or fail to prevent the danger that causes it. They are not ordinarily engaged where death results from a natural medical condition and the complaint concerns whether medical assistance might have been provided more promptly.

Judicial review of an inquest requires more than showing that particular questions might have been explored more fully. The claimant must show a fundamental failure of inquiry giving realistic prospects that the inquest and inquisition should be quashed and reopened.

The claimant sought permission to bring judicial review proceedings concerning an inquest into his wife's death while detained in a mental institution. He alleged that the coroner had failed to investigate possible delays and deficiencies in resuscitation, ambulance access, staff training and the deceased's wider medical treatment.

The coroner had declined to sit with a jury and had concluded that the inquest did not fall within the scope of Article 2. An earlier application for interlocutory relief had failed, and Underhill J had refused the renewed application on grounds including delay and merits. The central questions were whether Article 2 required a broader inquiry and whether the conduct of the inquest involved a fundamental failure warranting judicial review.

1. Permission refused. The claimant had no realistic prospect of setting aside the 2007 inquest and inquisition.
2. Article 2 was not engaged on these facts. The authorities referred to as Touche and Takoushis concerned fundamental failures which caused the condition leading to death, or failed to prevent the very danger that caused death. Here, the immediate cause was a natural heart attack. The complaint concerned whether prompt medical assistance might have prevented that natural cause from taking effect. That was a material distinction.
3. The circumstances did not require a broader inquest or an inquest with a jury under section 8 of the Coroners Act. The family's concerns about systemic failures, ambulance delay, resuscitation equipment and the deceased's prior treatment were understandable, but they did not establish the necessary wider inquiry.
4. The evidence did not demonstrate a fundamental failure of inquiry. The transcripts showed that nursing staff had provided some assistance and obtained equipment, and the expert had addressed the difficulty of clearing the airway. Questions might have been explored more fully, but that was not the test for judicial review.
5. The alleged absence or incomplete examination of medical notes and collateral issues concerning earlier treatment did not disclose a wholly ignored line of inquiry capable of shedding fresh light on the circumstances of death. The application was therefore refused.

This was a renewed first-instance application for permission to bring judicial review proceedings. An earlier application for interlocutory relief had been unsuccessful. Underhill J subsequently refused the application, including on grounds of inordinate delay and merits. Mr Justice Blake refused permission on renewal.