P, R (on the application of) v HM Coroner for the District of Avon

At an inquest engaging article 2 of the European Convention on Human Rights, the coroner must give the jury a clear opportunity to state its conclusions on the central factual issues. A short-form verdict of suicide or accident may have a narrative appended to it.

A direction which suggests that a narrative is available only instead of a short-form verdict may therefore be materially defective. Nevertheless, article 2 imposes an investigative obligation on the state as a whole. When deciding whether to order a fresh inquest, the court may consider the totality of the state’s investigative process. A thorough ombudsman investigation may fill the gap left by a defective inquest verdict and make a further inquest unnecessary.

A prisoner was found hanging in her cell. The inquest jury rejected suicide and returned a verdict of accident. It made no narrative findings about evidence criticising the prison’s management of her risk of suicide or self-harm.

One of the deceased’s children sought judicial review. The complaint was that the Deputy Coroner had wrongly suggested that a narrative verdict was available only as an alternative to suicide or accident. Beatson J dismissed the claim in [2009] EWHC 820 (Admin). He found no misdirection and held alternatively that the Prisons and Probation Ombudsman’s investigation meant that a fresh inquest was unnecessary.

The appeal concerned whether the summing-up was materially defective and, if so, whether article 2 required the verdict to be quashed and a new inquest ordered.

1. The appeal was dismissed unanimously. The Deputy Coroner had materially misdirected the jury, but the Court of Appeal upheld the refusal to quash the verdict or order a fresh inquest.

2. In an article 2 inquest, the coroner’s first task is to decide how best to elicit the jury’s conclusions on the central issues. The principal issues here were whether the deceased intended to take her own life and whether the system for preventing suicide or self-harm merited criticism. The direction suggested that a narrative could be returned only if neither suicide nor accident expressed the jury’s conclusions. It therefore effectively foreclosed a narrative appended to a short-form verdict. Since Middleton, there has been no legal impediment to appending a narrative to a verdict of suicide or accident.

3. The conventional direction for the part of the inquisition recording the time, place and circumstances of the injury did not cure the error. By instructing the jury to be brief, neutral and factual and to express no judgment or opinion, it tended against recording the evaluative factual conclusions required on the systemic issues. Nor could the absence of a narrative reliably support an inference that the jury had rejected any causal contribution by systemic acts or omissions as minimal or trivial.

4. Article 2 places its procedural obligation on the state, rather than solely on the coroner. Compliance must therefore be assessed by considering the whole investigative apparatus deployed by the state. The Prisons and Probation Ombudsman had investigated the death, made five recommendations and received input from the family. The report substantially filled the gap left by the limited jury verdict and made the overall investigation article 2 compliant.

5. The cases in which misdirection had resulted in a new inquest were distinguishable. Their errors also involved failures to leave relevant short-form verdicts. Given the Ombudsman’s report, the evidence that lessons had been learned and the difficulty identifying any further likely benefit, this was not a case for a new inquest.

• Court of Appeal (Civil Division): In [2009] EWCA Civ 1367, held that the summing-up was materially defective but dismissed the appeal because the wider investigative process satisfied article 2 and a new inquest was unnecessary.
• Administrative Court: Beatson J dismissed the judicial review claim in [2009] EWHC 820 (Admin). He found no misdirection and held alternatively that he would have refused a fresh inquest in view of the Ombudsman’s report and the overall circumstances.
• Coroner’s inquest: The jury rejected suicide and returned a verdict of accident without an appended narrative concerning the prison’s systems for preventing suicide or self-harm.