Hair, R (on the application of) v Her Majesty's Coroner for Staffordshire (South)

An inquest into a death in state custody must provide an effective investigation under Article 2 of the ECHR. That requires proper preparation, timely disclosure, the calling of relevant witnesses and adequate directions to the jury. A coroner must ensure that relevant evidence is heard, even if an adjournment is required. Rule 40 of the Coroner’s Rules 1984, which restricts factual addresses to the coroner or jury, is not incompatible with Article 2. The absence of factual submissions does not itself undermine an otherwise adequate summing-up. The inquisition may nevertheless be quashed where late disclosure, failure to call material witnesses and inadequate directions prevent the jury from properly evaluating significant evidence.

Rossana Hair sought judicial review of an inquest into the death of her son, David Hair, who died after being found with a ligature around his neck while imprisoned at HMP Stafford. She alleged that the inquest failed to satisfy the investigative obligation under Article 2 of the ECHR, principally because important adjudication documents were disclosed late, relevant witnesses were not called and the coroner failed to explain the significance of documentary evidence to the jury.

She also challenged Rule 40 of the Coroner’s Rules 1984, which prevented persons from addressing the coroner or jury as to facts. The issues were whether the inquest was sufficiently effective and whether Rule 40 was compatible with Article 2.

1. The inquisition was quashed and a new inquest ordered. In a death in state custody, Article 2 requires a full and effective investigation, with family participation, into the circumstances of the death. Timely disclosure is essential because it permits proper preparation and the identification and summoning of relevant witnesses.
2. The belated disclosure of the adjudication papers revealed the significance of a written statement indicating possible mental fragility and identified Tony Palmer, Prison Officer Tropietko and Governor Small as potentially relevant witnesses. The coroner was ultimately responsible for ensuring that all relevant witnesses were called, even at the expense of an adjournment.
3. The jury’s answer that there was no evidence that disciplinary staff knew of the written statement was perverse. The documentary record supported an inference that someone involved in the adjudication process had seen it. The coroner’s failure to direct the jury on that significance, together with the failure to call the relevant witnesses, fatally undermined the integrity of the inquest. Further evidence could also affect the jury’s conclusions concerning the management of the deceased’s refusal to leave segregation and the allegation of bullying.
4. Rule 40 was not incompatible with Article 2. No particular procedure is required provided that the investigation is effective and involves the deceased’s family. The ability to address the coroner or jury on facts is not an essential prerequisite. Any defect in the summing-up could be challenged directly; factual submissions were not necessary to make an otherwise adequate summing-up effective. The proposed reading-down of Rule 40 was therefore rejected.