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

This appeal concerned whether article 2 ECHR required the coroner to ask a jury to return an expanded (Middleton‑style) verdict under section 5(2) of the Coroners and Justice Act 2009 after the inquest into the death of Jacqueline ("Jackie") Maguire. The court analysed the distinction between the substantive positive obligations under article 2 — the systems duty and the operational duty — and the graduated procedural obligations (basic, redress and enhanced procedural obligations).

The Court held that an expanded verdict is required only where the enhanced procedural obligation under article 2 is engaged, which in turn arises only where there is an arguable breach of the substantive obligations (a systemic/structural failure or a targeted operational failing of the kind described in Osman and clarified in Fernandes and Oliveira) or in categories where that obligation arises automatically. The Supreme Court concluded that, on the evidence heard at the inquest, there was no arguable breach of the systems duty or of an Osman‑type operational duty by the care home or the healthcare providers such as to trigger the enhanced procedural obligation and require an expanded verdict.

The court emphasised that allegations of ordinary medical negligence, or discrete individual lapses, do not normally engage the systems duty or attract the enhanced procedural obligation: those instances are generally addressed by ordinary civil or disciplinary remedies and by a Jamieson‑style inquest which determines the cause of death. The Coroner’s decision to direct a short form verdict was therefore lawful and rational.

Background and procedural posture.

• Nature of the claim/application: judicial review by the deceased’s mother of the coroner’s decision (the "verdict decision" of 29 June 2018) not to request an expanded verdict at the jury inquest. The claimant sought declarations that article 2 was engaged and that a new inquest was required.
• Facts: Jacqueline Maguire, a vulnerable adult with Down’s syndrome and deprived of liberty by a DoLS authorisation, fell ill on 21–22 February 2017. Care‑home staff, NHS 111, out‑of‑hours GP advice and paramedics were involved; Jackie refused initial transfer on 21 February, was taken to hospital under light restraint on 22 February and died that evening from a perforated gastric ulcer, peritonitis and pneumonia. An inquest with a jury heard extensive evidence and expert reports.
• Appellate path: Divisional Court ([2019] EWHC 1232 (Admin)) dismissed the claim; Court of Appeal ([2020] EWCA Civ 738) dismissed the appeal; permission to appeal to the Supreme Court was granted.

Issues framed by the court.

• Whether the Coroner erred in law or acted irrationally in concluding article 2 did not require an expanded verdict under section 5(2) C&JA 2009.
• Whether there was an arguable breach of the systems duty by the care home or healthcare bodies such that the enhanced procedural obligation applied.
• Whether there was an arguable breach of the operational duty (Osman type) by the care home or healthcare providers requiring an expanded verdict.
• Whether general reports on mortality of people with learning disabilities (LDM Review, CIPOLD) altered the article 2 analysis.

Court’s reasoning.

• The court reviewed Strasbourg and domestic authority (notably Osman; Powell; Calvelli; Fernandes; Oliveira; Middleton; Rabone; Parkinson; Dumpe) and reiterated the tripartite division of procedural obligations (basic, enhanced, redress). Section 5(2) C&JA 2009 embodies Middleton’s requirement that, where necessary to avoid breach of Convention rights, the inquest must ascertain "in what circumstances" death occurred.
• Threshold for engaging the systems duty is high: only very exceptional systemic or structural failures (or denial of access to life‑saving emergency treatment) will establish a substantive article 2 breach of that type. Individual errors, negligent coordination or isolated lapses ordinarily do not.
• Operational (Osman) duty is focused and targeted: it protects against a known or ought‑to‑have‑known real and immediate risk to life. The coroner and courts must identify the specific risk of which the authorities were or should have been aware and ask whether reasonable steps to avert that risk were omitted.
• Applying these principles to the inquest evidence, the Coroner heard detailed systems and training evidence about the care home, NHS 111, ambulance service, GPs and hospital, and independent expert evidence that the paramedics’ and clinicians’ assessments fell within a reasonable range. The Coroner’s finding that deficiencies shown were individual lapses rather than systemic failures was open to him on the evidence.
• The Court rejected arguments that the mere fact of deprivation of liberty or vulnerability automatically engaged the enhanced procedural obligation. The LDM and CIPOLD reports did not identify a systems failure causatively connected to Jackie’s death; they could not substitute for the focused factual and legal threshold required by article 2.

Disposition. The Supreme Court dismissed the appeal: the Coroner did not err in law or act irrationally in directing a short form (Jamieson‑style) verdict and declining to seek an expanded verdict under section 5(2).

Appeal dismissed. The Supreme Court concluded that, judged on the evidence presented at the inquest, there was no arguable breach of the article 2 systems duty or of an Osman‑type operational duty by the care home or healthcare providers such as to engage the enhanced procedural obligation and require an expanded (Middleton‑style) verdict under section 5(2) of the Coroners and Justice Act 2009. Allegations of individual negligence or isolated lapses did not meet the high threshold for article 2 substantive breaches; the coroner’s decision to direct a conventional short‑form verdict was lawful and open on the evidence.

Judicial review in the Divisional Court: R (Maguire) v His Majesty’s Senior Coroner, Blackpool & Fylde, [2019] EWHC 1232 (Admin) — claim dismissed. Appeal to Court of Appeal: [2020] EWCA Civ 738 — appeal dismissed. Final appeal to the Supreme Court: [2023] UKSC 20 (this judgment).