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

Article 2 requires an effective investigation, but it imposes an obligation of means rather than a guaranteed result. Traditional short-form coronial verdicts remain available where they enable the jury to express its conclusions on the central issues. A coroner is not required to direct a jury to append a narrative to a short-form verdict. It is sufficient that the jury is given a genuine opportunity to return a narrative verdict if the short form does not express its factual conclusions. The court may infer from the verdict and the directions that the jury considered the short form sufficient, although caution is required when inferring what jurors decided.

The claimant challenged an inquest into her mother's death in custody. The coroner left suicide, accident and narrative verdicts to the jury, and directed that a narrative verdict could be returned if the short-form verdicts did not express the jury's factual conclusions. The jury returned an accident verdict. The claimant argued that Article 2 and R (Middleton) v West Somerset Coroner required the coroner to direct the jury that it could append a short narrative to a suicide or accident verdict, addressing issues such as the deceased's vulnerability and the adequacy of preventive precautions. The central issue was whether the directions unlawfully failed to secure conclusions on the circumstances leading to the death.

1. The application was dismissed. The coroner was not required to direct the jury expressly that it could append a narrative summary to a short-form verdict. That would effectively create a hybrid verdict.
2. Article 2 requires an effective official investigation, but the obligation is one of means or procedure, not result. The form of investigation is not prescribed, provided it is thorough, impartial and careful.
3. R (Middleton) v West Somerset Coroner did not abolish traditional short-form verdicts. Its references to enabling or permitting a jury to express its conclusions require the coroner to provide an adequate means of doing so, not necessarily a particular form of verdict.
4. Here, the jury was expressly offered a narrative verdict if suicide or accident did not express its factual conclusions. The twelve potentially relevant acts and omissions were placed before it. Section 3 of the inquisition also permitted the jury to record the circumstances in which the injury was sustained, irrespective of the verdict selected.
5. It was therefore permissible to infer that the jury considered the accident verdict sufficient and that the identified acts or omissions had not contributed to the death in more than a minimal or trivial way. Such inferences must, however, be drawn cautiously.
6. Since the investigation and evidence were not otherwise criticised, and the challenge to the summing-up was narrow, no new inquest or remission would have been ordered even if the direction had been defective.