Chambers v HM Coroner for Preston and West Lancashire & Ors

An irregularity in failing to notify an interested person of an inquest does not automatically invalidate the proceedings. The claimant must show that the irregularity was material, ordinarily by demonstrating insufficiency of inquiry.

Article 2 requires a rigorous, full and effective investigation into a death in custody, but it does not impose a universal requirement for independent psychiatric evidence in every prison suicide case. The coroner has a wide discretion as to the witnesses and expert evidence required. The adequacy of the inquiry depends on the facts, including whether the central factual issues were sufficiently investigated and put before the jury.

Stephen Chambers died by hanging in HMP Preston in January 2004. At the 2007 inquest, the jury returned a narrative conclusion identifying family problems and bullying as contributing factors. The deceased’s daughter, acting through her mother, had been an interested person, but her solicitors were not notified of the inquest hearing.

Following authorisation under section 13 of the Coroners Act 1988, she applied to quash the inquisition and obtain a fresh inquest. She alleged procedural irregularity and insufficiency of inquiry, particularly the absence of independent psychiatric evidence and the non-attendance of the prison doctor. The central issue was whether the original investigation was legally sufficient.

1. The application was refused. The court declined to quash the inquisition or direct a fresh investigation.

2. The failure to notify the claimant’s solicitors was an irregularity, because she was an interested person. It was not, however, automatically a material irregularity. If the inquiry was otherwise sufficient, the oversight did not vitiate the proceedings.

3. Article 2 requires an independent, effective and reasonably prompt investigation, with sufficient public scrutiny and appropriate involvement of the next of kin. In a prison death case the coroner must ensure that the inquiry is rigorous and full. The court rejected the submission that independent psychiatric evidence is required whenever a prison suicide may involve mental-health issues.

4. R (Wright) v Secretary of State for the Home Department and R (Warren) v HM Assistant Coroner for Northamptonshire were exceptional cases. They did not fetter the coroner’s discretion, which includes deciding whether to call expert witnesses. The need for such evidence must be determined on the facts of each case.

5. Here, the fresh psychiatric report identified a possible referral but did not support a formal depressive-disorder diagnosis or criticise the treatment actually provided. It therefore added little to the medical evidence and did not amount to substantial new evidence under section 13 of the Coroners Act 1988.

6. The inquest had sufficiently examined the management of suicide risk, including the self-harm procedures, the F2052SH process, its reviews and the decision to close the form. The jury had been permitted to make findings on other central facts, including defects in prison systems and their possible contribution to the death. The scope of inquiry was therefore sufficient for this case.

7. Although neglect was not left to the jury, there was no prospect of such a finding. In a suicide case, neglect requires a gross failure to provide basic care and a clear and direct causal connection with the death.

The judgment concerned a first-instance application for judicial review of a 2007 inquest. The claimant had obtained the Attorney General’s authorisation required by section 13 of the Coroners Act 1988. The High Court refused to quash the inquisition or order a fresh inquest.