Speck, R (on the application of) v HM Coroner for District of York & Anor

In an Article 2 inquest, the coroner must investigate matters which caused, or at least arguably caused or contributed to, the death. The coroner has a discretion to investigate matters which may possibly have contributed to the death, but has no duty, and no power under the statutory scheme, to investigate matters too remote to have arguably made a real contribution. That assessment may be made when deciding the scope of the inquest, before all evidence is heard. An issue may properly be excluded where it depends on speculation, lacks an arguable causal connection, or would require investigation of policy and resource allocation outside the statutory purpose of an inquest.

Miss Toni Speck died in police custody after being detained under section 136 of the Mental Health Act 1983. An Article 2 inquest was required. Her mother sought judicial review of the coroner’s ruling on the scope of the inquest.

The coroner included the circumstances of the arrest, detention, medical care and death, but excluded investigation of why York had no health-based place of safety, including alleged duties to provide such a facility and alleged misapplication of funding. The central questions were whether those matters were arguably causative of the death and whether the ruling was unlawful.

1. Permission refused. The claimant could not show that the coroner had applied an unlawful test or exercised his judgment perversely. No order as to costs was required by agreement.
2. Section 5 of the Coroners and Justice Act 2009 divides potential issues into three categories: matters the coroner must investigate; matters he has discretion to investigate; and matters on which he is not permitted to express an opinion. In an Article 2 inquest, the duty is limited to matters which caused, or at least arguably appeared to have caused or contributed to, the death. The decisions in R (on the application of Allen) v HM Coroner for Inner North London [2009] EWCA Civ 623 and R (Lewis) v Mid and North Shropshire Coroner [2010] 1 WLR 1836 were followed.
3. The possibility that an issue may have contributed to death gives rise to a discretion, but not a duty, to investigate it. The coroner may determine the scope of the inquest before hearing all evidence.
4. The claimant identified no arguable statutory or other duty requiring a health-based place of safety in York before June 2011. Section 135(6) of the Mental Health Act 1983 defined a place of safety but did not impose such a duty. Guidance making police-station use exceptional and healthcare accommodation preferable did not make a specialist facility legally mandatory.
5. The alleged funding issue could not establish an arguable causative breach. The evidence did not show when relevant funding became available, whether it was ring-fenced, or that a facility could have existed in time. Investigation would also require examination of policy and resource allocation and speculation about a hypothetical facility.
6. The coroner was therefore correct to exclude the non-availability of a health-based place of safety. Even if the issue fell within his discretion, the claimant failed to show the strong grounds required to overturn that judgment.

First-instance judicial review application. At the conclusion of the hearing, the court refused permission to apply for judicial review and reserved its reasons.