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

An Article 2 duty to investigate may arise when a detained mental patient dies, even where the death appears to result from a natural medical condition. It is enough that the detaining authorities may have failed in general or operational measures to protect life.

The investigation need not address every concern raised by the family. The coroner must focus on issues central, or arguably central, to the cause of death. Causation therefore remains relevant: matters with no possible causal connection need not be investigated.

Sandra Jane Allen died while detained under section 3 of the Mental Health Act 1983 at a mental health centre. The coroner concluded that she died from natural causes following a fatal cardiac arrhythmia caused by coronary artery disease.

Her widower sought judicial review and a fresh inquest, alleging that the investigation failed to examine possible choking, delays in resuscitation and ambulance access, oxygen-equipment problems, and decisions about her ward and dentures. Underhill J refused the initial application. Blake J refused the renewed application on the merits on 23 September 2008. The central issues on appeal were whether Article 2 was engaged and whether the inquest was sufficiently comprehensive.

Appeal dismissed. The Court of Appeal held that Article 2 of the European Convention on Human Rights was engaged, although the refusal of permission to seek judicial review was ultimately correct.

1. Engagement of Article 2. Blake J was wrong to approach engagement as confined to cases involving fundamental failures which caused the medical condition resulting in death. The authorities recognised the vulnerability of detained persons and the need for investigation where the state may have failed in general or operational measures to protect life. This included detained mental patients. The possibility of such a failure was sufficient; prior proof of breach was unnecessary. The approach in R (on the application of Smith) v Secretary of State for Defence [2009] EWCA Civ 441, Savage v South Essex NHS Trust [2008] UKHL 74 and R(L) v Home Secretary [2008] UKHL 68 supported that conclusion.
2. Scope of the investigation. Under R (Middleton) v West Somerset Coroner [2004] UKHL 10, the coroner had to focus the investigation and inquisition on the central issue or issues. He was not required to investigate every issue raised by the family, particularly matters which were not arguably central to the cause of death.
3. Causation. Causation remained relevant to an Article 2 investigation. The matters investigated had to concern an alleged breach which caused, might have caused, or might have contributed to the death. The treatment of the purposes of an Article 2 investigation in R (Amin) v Home Secretary [2003] UKHL 51 did not make causation irrelevant.
4. Application. The experts knew about food in the airway and nevertheless attributed death to coronary artery disease. The coroner identified the uncertainty about the timing of basic life support. The delay in admitting the ambulance did not affect the expert conclusion because the SHO had provided proficient life support. The oxygen-canister issue was not a defect because it could not have caused or contributed to the death. The questions about dentures and transfer to another ward were not even arguably possible causes. No failure to investigate a central causative issue or fresh line of inquiry was shown. The appeal was therefore dismissed.

• Court of Appeal (Civil Division): The appeal was dismissed. The court held that Article 2 was engaged but upheld the refusal of permission to apply for judicial review. [2009] EWCA Civ 623.
• High Court of Justice, Administrative Court: Blake J refused the renewed application for permission on the merits on 23 September 2008. Underhill J had earlier refused the paper application on grounds of delay and absence of legal error.