R (on the application of Maguire) v His Majesty’s Senior Coroner for Blackpool & Fylde and another

Article 2 imposes systems, operational and graduated procedural duties. An enhanced investigation is required automatically in certain categories of death or where an arguable breach of a substantive duty exists. Otherwise, alleged medical negligence ordinarily engages only a basic investigation and access to civil redress.

The systems duty requires an effective regulatory framework and appropriate institutional systems. Individual errors or negligent co-ordination do not themselves establish a systemic defect. The operational duty is directed to a specific, real and immediate risk to life which the authorities knew or ought to have known about. Vulnerability, deprivation of liberty and state-funded care do not alone make the state responsible for every aspect of a resident’s physical health.

A woman with Down’s syndrome, learning disabilities and limited capacity lived in a regulated care home under a deprivation of liberty authorisation. After becoming seriously ill, she was assessed by healthcare professionals but remained at the home overnight because she resisted hospital admission and they did not consider her life to be in danger. She was admitted the next morning and later died.

The Coroner conducted a jury inquest but, after hearing the evidence, decided that article 2 did not require an expanded verdict under section 5(2) of the Coroners and Justice Act 2009. The Divisional Court dismissed the family’s judicial review claim: [2019] EWHC 1232 (Admin). The Court of Appeal dismissed an appeal: [2020] EWCA Civ 738; [2021] QB 409.

The central question was whether an arguable breach of the systems duty or operational duty by the care home or healthcare providers triggered the enhanced procedural obligation under article 2 and therefore required an expanded verdict.

1. Appeal dismissed unanimously. Lord Sales delivered the judgment with which Lord Reed, Lord Lloyd-Jones and Lady Rose agreed. Lord Stephens agreed with the result and the principal analysis.

2. Article 2 gives rise to a systems duty, an operational duty and graduated procedural obligations. The enhanced procedural obligation applies automatically in recognised categories or where an arguable breach of a substantive article 2 duty exists. Ordinary allegations of medical negligence generally require an investigation into the cause of death and an available civil remedy, rather than an expanded inquest verdict.

3. There was no arguable breach of the systems duty by the care home. An effective regulatory regime existed under the supervision of the Care Quality Commission. The home also had systems for staff training, record-keeping, communication and obtaining medical assistance. The systems were capable of operating effectively. Any failures were individual lapses rather than defects in the systems themselves. The systems duty is assessed prospectively by considering what arrangements it was reasonable to have in place before an incident. It cannot ordinarily be constructed retrospectively from everything that went wrong.

4. There was likewise no arguable systems breach by the healthcare providers. The ambulance service had arrangements for assessing patients lacking capacity and obtaining medical advice. Errors by individual clinicians and a failure to transmit all information through NHS 111 did not establish systemic or structural dysfunction.

5. The operational duty is targeted upon a specific risk to life which the authorities knew or ought to have known about. Placement in a care home, vulnerability and deprivation of liberty did not make the state responsible for every aspect of the resident’s physical health. The care home’s responsibility was to secure access to generally available healthcare. Its staff did so by seeking medical advice and calling an ambulance, and were entitled to rely upon the resulting professional assessments.

6. The healthcare professionals were not on notice of a real and immediate risk to life. The paramedics considered whether restraint or sedation was justified and reasonably concluded that the perceived risk did not warrant forcing the resident to hospital. Respect for dignity, autonomy and trust, and the potential harm caused by restraint, were relevant considerations. The case did not fall within the very exceptional category of a knowing denial of life-saving emergency treatment.

7. Accordingly, the enhanced procedural obligation did not apply. Section 5(2) of the Coroners and Justice Act 2009 neither required nor permitted an expanded verdict. The Coroner lawfully directed the jury to return a short-form verdict.

8. Lord Stephens cautioned against glossing the established “real and immediate risk” criterion with the expression “a particularly clear and pressing” risk. He also emphasised that, once the enhanced procedural obligation applies, the state must investigate of its own motion.

1. United Kingdom Supreme Court: The appeal was dismissed unanimously: [2023] UKSC 20 . The Coroner had lawfully concluded that article 2 did not require an expanded verdict.
2. Court of Appeal: The appeal from the Divisional Court was dismissed: [2020] EWCA Civ 738 ; [2021] QB 409 .
3. Divisional Court of the High Court: The judicial review claim challenging the Coroner’s verdict decision was dismissed: [2019] EWHC 1232 (Admin) .