Iroko, R (On the Application Of) v HM Senior Coroner for Inner London South & Anor

In medical-death cases, the procedural obligation under article 2 of the European Convention on Human Rights arises where the evidence discloses a systemic or structural dysfunction in healthcare services, or a comparable exceptional circumstance, rather than ordinary clinical negligence or individual error. The relevant dysfunction must be objectively identifiable, attributable to the state, linked to the harm, and connected with a failure to provide the necessary regulatory framework. Allegations of individual failings must not be presented as systemic shortcomings without evidential support.

Neglect in an inquest requires a gross failure to provide basic medical attention, a threshold materially higher than clinical negligence. A Prevention of Future Deaths report is fact-specific and involves evaluative judgment by the coroner.

The claimant challenged decisions made during the inquest into her mother’s death after treatment at hospitals operated by the interested NHS Trust. The Senior Coroner ruled that an article 2 inquest was not required, because there was no evidence of systemic failure or a failure to establish a regulatory framework. The Assistant Coroner later declined to make findings of neglect or issue a Prevention of Future Deaths report.

The claimant alleged errors concerning the scope of the inquest, the failure to investigate neglect, and the failure to issue a report addressing future risks. The central issues were whether the evidence required an article 2 investigation, whether the alleged clinical and record-keeping failures amounted to neglect, and whether the Assistant Coroner had arguably erred in declining to issue a report.

1. Article 2. The claim was dismissed. In medical-negligence cases, the procedural obligation under article 2 requires an inquest into the circumstances of death only where the applicable exceptional circumstances are established. The relevant test requires cumulative consideration of whether healthcare providers denied emergency treatment despite knowing that life was at risk, whether the dysfunction was objectively and genuinely systemic or structural, whether it was linked to the harm, and whether it resulted from failure by the state to provide the necessary regulatory framework. Ordinary negligence and individual clinical error do not satisfy that test: R (Maguire) v HM Senior Coroner for Blackpool and Fylde [2020] EWCA Civ 738; Lopes de Sousa Fernandes v Portugal (2018) 66 EHRR 28; R (Parkinson) v HM Senior Coroner for Inner London South [2018] EWHC 1501 (Admin).
2. The DNR policy formed part of the regulatory framework and required clinicians to obtain and record relatives’ views where appropriate. Any failure by an individual clinician to comply with it was an individual error in the face of systemic requirements, not itself a systemic failure. The evidence did not establish that errors in recording the DNR discussion or venous gas timings resulted from a wider maintenance or record-keeping dysfunction. The court warned against dressing up potentially negligent acts as systemic failings.
3. The evidence concerning other patients, alleged poor record-keeping, the DNR decision, and the hospital survey did not establish a systemic failure connected with the death. The coroners were therefore entitled to conclude that section 5(2) of the Coroners and Justice Act 2009 did not require an article 2 inquest.
4. Neglect. Neglect in this context requires a gross failure to provide basic medical attention, including failure to provide attention obviously required by a dependent person. Even if the discharge decision had been clinically negligent, it fell well short of that narrow threshold. The Assistant Coroner was entitled, and right, not to make a finding of neglect: R v HM Coroner for North Humberside ex parte Jamieson [1995] QB 1.
5. Prevention of Future Deaths report. The duty to issue such a report under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and regulation 28 of the Coroners (Investigations) Regulations 2013 is highly fact-specific and involves an exercise of judgment. In light of the conclusions on article 2 and neglect, the Assistant Coroner had not arguably erred in declining to issue a report. The claim was dismissed.

First-instance judicial review proceedings in the Administrative Court. The judgment records the earlier preliminary ruling by the Senior Coroner and the subsequent inquest decision by the Assistant Coroner, but gives no separate citation for either decision.