Maguire, R (On the Application Of) v United Response & Ors

Article 2 is not engaged by every death of a vulnerable person receiving state-funded care. The essential question is whether the circumstances call the state to account because it assumed responsibility for the person’s welfare or safety, or because systemic or regulatory dysfunction contributed to the death. Individual negligence and errors of professional judgment generally do not suffice in a medical case.

Deprivation of liberty under the Mental Capacity Act 2005 does not automatically trigger Article 2 protection. The issue is fact-sensitive and turns on the degree of state control and the nature of the alleged failure.

Neglect in an inquest requires evidence of a gross failure to provide basic medical attention to a dependent person, together with a clear and direct causal connection with the death. Individual failings may be assessed cumulatively, but the evidence must safely support that conclusion.

Jacqueline Maguire, a woman with Down’s syndrome and learning difficulties, died after developing a perforated gastric ulcer while living in a residential care home. The Senior Coroner conducted a jury inquest and initially treated Article 2 as engaged. Following R (Parkinson) v Kent Senior Coroner [2018] EWHC 1501 (Admin), he concluded that the alleged failures were individual medical or caregiving failings and that Article 2 was not engaged.

The Coroner also declined to leave neglect to the jury, finding no individual gross failing and no sufficiently clear causal connection. The claimant sought judicial review of both decisions. The central issues were whether Article 2 applied and whether the evidence was sufficient to require a jury direction on neglect.

1. Application dismissed. The Divisional Court held that the Coroner had made no error of law in deciding that Article 2 was not engaged or in refusing to leave neglect to the jury.
2. Article 2 may apply beyond detention where the state has assumed responsibility for an individual’s welfare or safety, or where systemic or regulatory dysfunction is alleged. The touchstone is whether the circumstances call the state to account. The degree of state control is relevant, but the circumstances must be assessed factually.
3. The alleged failures, including the failure to make a home visit, inadequate triage, limited NHS111 advice, communication difficulties and the inability to convey the deceased to hospital, were individual failings. They did not demonstrate systemic dysfunction or regulatory failure. The court also held that evidence not placed before the Coroner could not be relied upon to impugn his ruling.
4. Deprivation of liberty under the Mental Capacity Act 2005 does not automatically make Article 2 applicable. A person subject to DOLS, but not imprisoned or detained, may fall within Article 2 depending on the facts. The Coroner was entitled to treat the case as a medical case and conclude that the evidence did not safely establish a state responsibility for the death.
5. Neglect has a restricted meaning in coronial law. In a medical context it requires a gross failure to provide basic medical attention to a person in a dependent position, together with a clear and direct causal connection with the death. The Coroner was entitled to consider both individual and cumulative failings, but correctly concluded that no individual failing was arguably gross and that the evidence did not safely support a finding of neglect.
6. The court emphasised that rejecting the Article 2 and neglect challenges did not diminish the importance of a full factual investigation at inquest.

First-instance judicial review proceedings. Permission was initially refused and was later granted by Supperstone J on 6 February 2019. The Divisional Court dismissed the application.