Joanne Patton, R (on the application of) v Her Majesty’s Assistant Coroner for Carmarthenshire and Pembrokeshire

The enhanced investigative duty under Article 2 is not confined to cases in which the state has assumed responsibility for, or exercised control over, the deceased. The general duty concerns the adequacy of the legislative, administrative and regulatory framework for protecting life. The court must distinguish systemic failures from individual negligence. The threshold for an arguable breach is low, but requires a real evidential basis and a link between the alleged breach and the harm. Where a child’s entitlement to accommodation is disputed, the decision-maker must assess the statutory criteria objectively, including whether existing accommodation is suitable. Reasons must address the principal controversial issues. A flawed Article 2 ruling may be quashed and remitted for reconsideration.

The claimant challenged the assistant coroner’s ruling that the inquest into her sixteen-year-old daughter’s death would not investigate the circumstances in which she came by her death under section 5(2) of the Coroners and Justice Act 2009, because Article 2 was not engaged.

She argued that the local authority arguably owed duties to provide accommodation under sections 76(1)(c) and 76(3) of the Social Services and Well-being (Wales) Act 2014, and that failures by the authority, mental health services and police arguably engaged the Article 2 general duty. The issues were whether the coroner had applied the accommodation duties correctly, given adequate reasons, and reached a lawful conclusion on the section 5(2) question.

1. Claim succeeded. The coroner’s ruling dated 8 August 2021 was quashed and the section 5(2) issue was remitted for fresh determination.
2. The claim was not premature. A ruling on the applicability of Article 2 was a legal decision with immediate practical consequences, including consequences for representation and funding. It was appropriate to correct any error before the inquest proceeded on a potentially unlawful basis.
3. The Article 2 general duty is concerned with the state’s legislative, administrative and regulatory framework for protecting life. Assumption of responsibility, control over the individual and particular vulnerability are relevant principally to the operational duty, not prerequisites for the existence of the general duty.
4. The coroner should have considered whether the general duty applied in principle to the local authority, police and Health Board, then separately considered whether there was an arguable systemic breach. The threshold is low, but the case must have a real evidential basis rather than mere speculation. Individual negligence and failures of co-ordination do not, without more, establish a systemic failure. Causation requires a link between the alleged breach and the harm, applying the loss of a substantial chance of a different outcome test.
5. Applying Salford City Council v W, the court must make its own objective assessment under section 76(1)(c), rather than treating the local authority’s view as determinative. That assessment includes whether the child’s existing accommodation is suitable. The coroner erred by focusing on the fact that the child had accommodation and by failing clearly to distinguish the statutory-duty issue from the arguable-breach issue.
6. The reasons for rejecting section 76(3) were inadequate. Merely restating the statutory test did not explain how the principal controversy—whether accommodation permitting cannabis use, in the context of mental-health difficulties, seriously prejudiced the child’s well-being—had been resolved.
7. The court declined to determine the Article 2 issue itself. The coroner had not clearly addressed arguable breaches by all relevant bodies or causation, so a fresh, fully reasoned decision was required.

This was a first-instance judicial review claim. The court quashed the assistant coroner’s ruling dated 8 August 2021 and remitted the issue for re-determination.