Diarra Dillion, R (on the application of) v HM Assistant Coroner for Rutland & Ors

A coroner must make a prevention of future deaths report under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 when the statutory criteria are met. The coroner must rationally assess whether action should be taken, but that assessment contains a significant subjective element. Different coroners may reasonably reach different conclusions.

The question whether remedial action is required may be assessed by reference to the emergency response as a whole, rather than an isolated deficiency. A coroner may consider whether practical measures have already been implemented or are likely to be implemented, including realistic resource constraints. Such measures may make a formal report unnecessary. Judicial review does not permit the court to reweigh witness evidence or substitute its own assessment.

The claimant sought judicial review of the decision of the HM Assistant Coroner for Rutland and North Leicestershire not to make a prevention of future deaths report following an inquest into the death of his brother, a prisoner at HMP Stocken.

The challenge concerned the absence of universal first-aid training for prison officers on patrol-state duty, the absence of healthcare cover during certain hours, and staff understanding of emergency procedures. The claimant argued that the coroner had acted irrationally, fettered her discretion and misapplied the statutory framework. The central issue was whether the coroner had lawfully concluded that the threshold for a report was not met.

1. Claim dismissed. The coroner’s decision was lawful.
2. Paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 imposes a duty to report where the investigation gives rise to concern about circumstances creating a future risk of death and, in the coroner’s opinion, action should be taken to prevent or reduce that risk. The second criterion contains a significant subjective element. The coroner must act rationally, but there is no single objectively correct answer.
3. The coroner was entitled to assess first-aid provision as part of the prison’s emergency response as a whole. On the evidence, a prompt Code Blue would bring first-aid-trained responders and a trained custodial manager to the cell within approximately one or two minutes. The coroner could therefore conclude that first aid would be available without requiring every patrol officer to be trained.
4. The coroner was entitled to treat improved staff understanding, spot checks and the new medical emergency guidance as appropriate measures addressing the risk. Existing or committed remedial action could make a formal report unnecessary.
5. Under Rule 20 of the Prison Rules 1999, healthcare for prisoners had to be equivalent to NHS healthcare in the community. The court was not persuaded that the response time, if emergency procedures were properly followed, failed that test.
6. The coroner’s comments about lacking enforcement powers were infelicitous but formed part of discussions with counsel, not the operative decision. The statutory reference to action that should be taken was broad enough to permit consideration of what could practically be achieved, including resource implications and the realistic prospect that a report would be acted upon.
7. There was insufficient evidence of a national risk to require a report concerning national prison healthcare provision. Both grounds of challenge failed.

The claim arose from an inquest held before the HM Assistant Coroner for Rutland and North Leicestershire from 18 to 20 October 2021. On 20 October 2021 the coroner declined to make a prevention of future deaths report. The High Court dismissed the judicial review claim.