Palmer & Anor, R (on the application of) v Worcestershire County HM Coroner & Ors

Article 2 requires effective systems protecting life, but it does not convert individual failings within an adequate system into a systemic breach. The operational obligation arises only where an authority knew or ought to have known of a real and immediate risk to life and failed to take all reasonable steps to avoid it. That is a high, fact-sensitive threshold assessed without hindsight. A social services authority does not assume responsibility for preventing violent crime merely because it provides community care services. Where there is no arguable substantive breach, no enhanced investigation is required and a coroner may lawfully refuse to resume an inquest.

Adrian Palmer, a vulnerable adult with Asperger’s Syndrome, was killed by Ben Murphy after an earlier allegation of rape, threats and police and social-services involvement. Murphy was convicted of manslaughter after two inconclusive murder trials. The claimants, Adrian’s grandparents, sought judicial review of the coroner’s refusal to resume the adjourned inquest after criminal proceedings.

They argued that the police and county council had breached Article 2 by failing to maintain adequate protective systems and by failing to protect Adrian from a real and immediate risk to life. They also argued that the investigations already undertaken were insufficient to discharge the procedural investigative obligation.

1. Claim dismissed. The police and the council had not arguably breached either the general or operational substantive obligations under Article 2. The coroner was therefore not obliged to resume the inquest, and his decision was lawful under section 16(3) of the Coroners Act 1988.
2. The general obligation requires a state to maintain a framework of laws, precautions, procedures and enforcement machinery capable of protecting life. It is concerned with systemic deficiencies, not every failure by an individual officer or social worker. The evidence showed relevant police procedures, social-care arrangements, vulnerable-witness procedures and inter-agency guidance. Any shortcomings in implementation fell well short of systemic failure.
3. The operational obligation requires knowledge, actual or constructive, of a real and immediate risk to the particular individual’s life, together with failure to take all reasonable steps to avoid that risk. The risk must be real rather than fanciful, but the threshold is high and the assessment must avoid hindsight. The history of threats and minor violence did not make a fatal street attack reasonably foreseeable on the information available at the time.
4. The council’s community-care responsibilities did not make it responsible for preventing violent crime. The primary responsibility, resources and powers for that purpose lay with the police. Nor did Adrian’s non-coercive supervision order create the degree of compulsory state control found in detention cases.
5. It was unnecessary to decide whether the existing investigations would have satisfied Article 2. Nevertheless, had an arguable breach existed, the criminal proceedings, independent IPCC investigation, social-care investigation, published reports, family participation, recommendations and remedial steps would, in their totality, have been sufficient. An enhanced inquest need not determine causation where that issue could appropriately be addressed in civil proceedings.

First-instance judicial review proceedings. The challenge to the coroner’s refusal to resume the inquest was dismissed.