Tyrrellv HM Senior Coroner County Durham And Darlington (Rev 1)

A death in state custody does not automatically trigger the procedural investigation required by article 2 ECHR. That obligation arises where there are grounds to suspect that the state may have breached a substantive article 2 duty, including the duty to protect life. A natural death will therefore require an article 2-compliant inquest only where there is reason to believe that the state failed to provide appropriate medical care or otherwise failed to safeguard life. Every custodial death must nevertheless be independently investigated and explained under the coronial regime.

The claimant challenged the coroner’s decision that article 2 ECHR did not require an enhanced inquest into her father’s death while serving a prison sentence. He died in hospital from pneumonia secondary to cancer. Investigations by the Prison and Probation Ombudsman, medical experts and the coroner found no negligence, systemic failure or inadequate treatment, and established that the death was from natural causes.

The central issue was whether custody alone required a Middleton inquest, or whether the procedural obligation under article 2 arose only where the state’s substantive obligations were arguably engaged.

1. Claim dismissed. The coroner was entitled to conclude that the procedural obligation under article 2 ECHR was not engaged.
2. The Coroners and Justice Act 2009 requires an investigation into deaths in custody and ordinarily requires an inquest. Its purpose includes establishing who died, how, when and where the death occurred, and, where necessary to avoid a breach of Convention rights, the circumstances in which the deceased came by the death.
3. The statutory requirement for an inquest into every custodial death does not mean that every such inquest is an article 2 inquest. The distinction between a Middleton inquest and a Jamieson inquest concerns the permissible conclusion, rather than the general scope of inquiry.
4. The positive obligations under article 2 require the state to account for the cause of a death in custody. The procedural obligation to conduct an effective, independent investigation arises only where there is reason to believe that the state may have breached a substantive obligation to protect life. Suspicious deaths, including apparent suicides, ordinarily meet that threshold.
5. Where a prisoner’s death is clearly from natural causes and there is no reason to believe that the state failed to provide timely and appropriate medical care or otherwise failed to protect life, the procedural obligation is not triggered. The Osman v United Kingdom test applies in the medical-care context.
6. Chief Coroner guidance is not binding or authoritative, but the guidance stating that natural deaths in state detention do not necessarily require an article 2 inquest was endorsed as legally correct. In appropriate cases, independent certification of the cause of death may discharge the state’s obligation to establish that cause, and a forensic post-mortem examination may be unnecessary.

Not stated in the judgment.