Lewis, R (on the application of) v HM Coroner for Mid & North Division of the County of Shropshire & Anor

In an Article 2 inquest, the jury’s verdict may address the chain of events causally relevant to the death, including causative systemic failures. Article 2 does not require the jury to make findings about matters which neither caused nor contributed to the death, or about hypothetical measures that might have prevented it. The coroner may investigate more widely and may report concerns under rule 43, but the jury’s verdict remains confined to causally relevant facts. A jury may express judgmental factual conclusions and use terms such as “because” and “contributed to”, provided the verdict does not determine criminal or civil liability. An ancillary verdict of neglect should be left to the jury where evidence could establish gross failures and a clear and direct causal connection with the death.

Three linked judicial review claims concerned inquests into the deaths in custody of Karl Lewis, Paul Calvert and Stephen Woods. The challenges concerned the scope of Article 2 investigations, directions restricting narrative verdicts to causally relevant matters, directions requiring neutral and non-judgmental conclusions, and the refusal to leave a verdict of neglect.

The court dismissed the claims concerning the inquests into Karl Lewis and Stephen Woods. It upheld both challenges concerning Paul Calvert’s inquest, where the coroner had prohibited judgmental factual conclusions, prohibited the words “because” and “contributed to”, and refused to leave neglect to the jury.

1. JR1 dismissed. The coroner lawfully excluded questions concerning the actions taken after Karl Lewis was found hanging. In an Article 2 inquest, “how” in section 11(5)(b)(ii) of the Coroners Act 1988 and rule 36(1)(b) of the Coroners Rules 1984 means the means and circumstances causally relevant to, and leading to, the death. Article 2 does not require findings on events which could not have caused or contributed to the death. A coroner may investigate more widely, but the jury need not return conclusions on matters of merely speculative or hypothetical relevance.
2. The Article 2 investigative obligation is distinct from the substantive obligation to protect life. Its purpose is to establish the cause or causes of death and those responsible. It does not require an inquest to determine whether the State breached its substantive Article 2 or Article 3 obligations. Rule 43 gives the coroner, not the jury, responsibility for reporting concerns about preventing future deaths.
3. JR2 allowed. The directions in Paul Calvert’s inquest that the jury must use neutral, non-judgmental language and must not use “because” or “contributed to” were unlawful. A jury may record judgmental conclusions of fact directly relating to the circumstances of death, subject to rules 36 and 42 of the Coroners Rules 1984. The misdirections were likely to have prevented conclusions on central issues, including the failure to respond to the emergency alarm.
4. The refusal to leave neglect was also unlawful. The evidence could have enabled a properly directed jury to find gross failures by prison staff and systems, forming part of a clear and direct chain of causation leading to death. The inquisition was quashed and a new inquest ordered.
5. JR3 dismissed. Although the opening direction that the jury must not be judgmental was capable of criticism, the summing-up, read as a whole, correctly explained that judgmental factual conclusions were permissible where causative and where they did not determine civil or criminal liability. The causative-factor direction was lawful.

These were first-instance linked judicial review claims in the Administrative Court. The court dismissed the claims concerning the inquests into Karl Lewis and Stephen Woods, and quashed the inquisition concerning Paul Calvert, ordering a new inquest.