Warren, R (on the application of) v Her Majesty's Assistant Coroner for Northamptonshire

An Article 2-compliant inquest into a death in prison must investigate relevant medical and healthcare systems, while avoiding findings of criminal or civil liability. Where the circumstances indicate significant mental disturbance before the death, independent expert evidence may be required to assist the jury. The standard of healthcare expected in prison is relevant, including the standard available to the general public through the NHS.

A coroner retains a wide discretion over the witnesses to be called. The court should be slow to interfere with that discretion, but may intervene where the proposed arrangements would leave a material evidential gap. The decision was confined to the particular facts and did not establish that similar evidence is required in every prison-suicide inquest.

Michael Bailey committed suicide in the segregation unit of Rye Hill Prison after displaying unusual behaviour suggestive of a psychotic episode. Following criminal proceedings against prison officers and an investigation by the Prisons and Probation Ombudsman, an inquest was due to resume.

The claimant, Mr Bailey's mother, sought judicial review of the coroner's decision not to call Dr Trevor Turner, a consultant psychiatrist. The central questions were whether the proposed evidence was relevant to an Article 2-compliant inquest, whether independent psychiatric and general-practitioner evidence was required, and whether NHS standards were relevant to the assessment of prison healthcare.

1. Article 2 scope. The inquest had to investigate how and in what circumstances Mr Bailey died, within the parameters identified in R (Middleton) v West Somerset Coroner [2004] 2 AC 182. It had to avoid determining criminal or civil liability, but that limitation did not exclude investigation of the adequacy of the prison's medical support systems.
2. Relevant expert evidence. On the facts, Mr Bailey had become significantly mentally disturbed shortly before his death. Independent expert evidence at consultant psychiatrist level, and at general-practitioner level, might assist the jury in assessing the relevant systems and the care provided. An inquest without access to such evidence would not comply with Article 2.
3. NHS standard. The standard of healthcare expected in prison was the NHS standard available to the general public. Evidence of that standard was therefore relevant to the adequacy of the healthcare systems and the conduct of those operating them. The possibility that the evidence might overlap with issues of civil liability was a reason to control its presentation, not to exclude it in principle.
4. Coroner's discretion. The coroner alone decides which witnesses it is expedient to call and has a wide discretion in conducting an inquisitorial inquiry. The court would be slow to interfere with the refusal to call a particular witness, and the decision not to call Dr Turner was not so obviously wrong as to justify quashing it. Nevertheless, the overall evidential arrangements had to fill the identified gap. The court did not order that Dr Turner himself be called, leaving the practical response to the coroner.
5. The specific relief sought was refused. No declaration or mandatory order was made, and there was no order as to costs. The claimant, being publicly funded, was granted detailed assessment. The conclusion was expressly confined to the facts of this case.