Maguire, R (on the opplication of) v HM Senior Coroner for Blackpool & Fylde & Ors

The article 2 operational duty owed to a vulnerable person in state-supported residential care is specific to harms for which the state has assumed responsibility. It does not govern every aspect of that person’s medical treatment.

A death following alleged failures in ordinary medical care engages the operational duty only in the very exceptional circumstances identified for medical cases. These include knowing denial of life-saving emergency treatment or a systemic or structural dysfunction attributable to failure of the state’s regulatory framework.

Unless there is reason to believe that a substantive article 2 obligation may have been breached, the parasitic procedural duty does not require an expanded inquest conclusion under section 5(2) of the Coroners and Justice Act 2009.

Jacqueline Maguire was a vulnerable adult with Down’s Syndrome, learning disabilities and impaired capacity. She lived in a privately managed residential care home under arrangements funded and supervised by a local authority and was subject to a deprivation of liberty authorisation. After becoming acutely ill, she declined to go to hospital when paramedics attended. Medical professionals decided that she could remain under observation overnight. She was taken to hospital the following morning and died from a perforated gastric ulcer, peritonitis and pneumonia.

The coroner ruled that the evidence did not suggest a possible violation of the article 2 operational duty. He therefore confined the jury to the questions in section 5(1) of the Coroners and Justice Act 2009. The jury returned a conclusion of death by natural causes with a short narrative.

The Divisional Court dismissed the family’s judicial review claim in [2019] EWHC 1232 (Admin). The appeal asked whether Jackie’s vulnerability and deprivation of liberty engaged the article 2 operational duty, whether the absence of a plan for urgent hospital admission disclosed systemic dysfunction, and whether evidence about premature deaths among people with learning disabilities affected those questions.

1. Appeal dismissed. The coroner was entitled to conclude that there was no basis for believing that the death resulted from a breach of the state’s operational duty under article 2. The procedural obligations identified in Jordan therefore did not arise. The inquest conclusion was governed by section 5(1), rather than section 5(2), of the Coroners and Justice Act 2009.
2. The unifying feature of the operational duty is state responsibility. The duty is tailored to harms against which public authorities have assumed responsibility to protect the person concerned. Vulnerable people in state care may accordingly be protected against institutional abuse, neglect, dangerous conditions or other defined risks within the authorities’ control. That does not mean that every death of such a person, or every aspect of ordinary medical treatment provided to that person, falls within the operational duty.
3. Jackie’s deprivation of liberty authorisation and vulnerability did not make her position analogous to that of a psychiatric patient admitted because of a risk of suicide. She lived in the home so that carers could support her daily life, not to obtain medical treatment or protection against the particular risk which caused her death. When treatment was required, it was sought from ordinary NHS services. The alleged shortcomings therefore fell to be analysed as a medical case.
4. In a medical case, substantive article 2 responsibility arises only in very exceptional circumstances. Knowing denial of life-saving emergency treatment was not established because the professionals collectively judged that Jackie was not in immediate danger. Nor was there an objectively identifiable systemic or structural dysfunction attributable to a failure of the state’s regulatory framework. Alleged failures to devise an individual admission plan, protocol or guidance were far removed from such a regulatory failure.
5. It was unnecessary to determine whether the professionals knew or ought to have known of a real and immediate risk of death under the Osman test. If that issue had arisen, the less stringent scrutiny applicable outside prisons and involuntary psychiatric detention would have applied. The retrospective expert evidence did not establish that the professionals ought at the time to have appreciated the high mortality risk.
6. The reports concerning reduced life expectancy among people with learning disabilities did not illuminate the circumstances of this death and added no weight to the contention that the relevant operational duty arose.

1. Court of Appeal (Civil Division): By [2020] EWCA Civ 738 , dismissed the appeal and upheld the conclusion that section 5(2) of the Coroners and Justice Act 2009 did not apply.
2. High Court, Divisional Court: In [2019] EWHC 1232 (Admin) , dismissed the claim for judicial review of the coroner’s decision. It held that article 2 state responsibility required either systemic dysfunction arising from regulatory failure or a relevant assumption of responsibility.
3. Coroner’s court: The coroner ruled that the article 2 procedural duty did not arise and confined the jury’s conclusion to section 5(1). The jury concluded that the death resulted from natural causes and added a short narrative.