Jada Bailey, R (on the application of) v HM Senior Coroner for East London

An Article 2 investigative obligation does not prescribe a single procedure. The obligation may be discharged by several investigations considered cumulatively, provided that the process is independent, effective, reasonably prompt, sufficiently subject to public scrutiny, and involves the next of kin to the extent necessary to safeguard legitimate interests.

The purpose is principally to establish what happened and secure accountability. It does not require an investigation to determine what public authorities should have done, although such conclusions may follow from findings about past events. A coroner deciding whether to resume an inquest may consider whether further conclusions would materially add to investigations already completed.

The claimant sought judicial review of the HM Senior Coroner for East London’s refusal to resume the inquest into her 14-year-old son’s death. The inquest had been adjourned after a murder charge and was not resumed following the defendant’s conviction. The claimant relied on an Article 2 procedural obligation, alleged errors concerning the utility of a resumed inquest, and failure to consider relevant matters.

The investigation included the criminal proceedings, a serious case review, and police complaint investigations. The central issues were whether those investigations cumulatively satisfied Article 2 and whether the coroner had misunderstood the possible conclusions or value of a resumed inquest.

1. Application dismissed. The coroner’s decision that the Article 2 investigative obligation had been discharged was lawful.
2. Article 2 may require an effective public investigation where a substantive obligation may have been violated and state agents may be implicated. The investigation must be independent, effective, reasonably prompt, sufficiently subject to public scrutiny, and involve the deceased’s next of kin to the extent necessary to safeguard legitimate interests. The obligation is flexible and may be satisfied by separate investigations considered cumulatively. No particular procedure, public hearing, power to compel evidence, or opportunity for the family to test evidence is invariably required.
3. The serious case review was capable in principle of satisfying Article 2. Its author was independent. The report was thorough, identified the relevant public authorities’ acts and omissions, and provided sufficient public scrutiny and accountability. The claimant had a real and substantial opportunity to participate, although she chose to communicate principally through her solicitors.
4. The investigation’s purpose was to establish what had happened. Section 5 of the Coroners and Justice Act 2009 required the inquest to determine who the deceased was and how, when, where, and in what circumstances he came by his death. Section 10 prevented conclusions from appearing to determine civil liability. Identifying what should have happened could be a by-product, but was not the essential investigative purpose.
5. The coroner had not erred by referring to an unlawful-killing conclusion rather than separately considering a narrative conclusion. Nor was describing a regulation 28 report as having limited force a material misdirection: such a report is not prescriptive and cannot require a particular remedial solution.
6. The coroner had considered the public interest, the statutory purpose of an inquest, the possibility of public reassurance, and a regulation 28 report. The claim was dismissed.

Not stated in the judgment.