David Ferguson, R (on the application of) v HM Assistant Coroner for Sefton, Knowsley and St Helens

Before an inquest has heard the evidence, the threshold for engaging the enhanced investigative duty under Article 2 applies both to the existence of the positive operational duty and to an arguable breach of it. The threshold is low: there must be a real evidential basis making the alleged breach credible, rather than proof on the balance of probabilities.

The positive operational duty may arise where police officers respond to a vulnerable person facing an arguable, real and immediate risk of suicide. The risk may be present and continuing without being imminent. Individual operational failings do not, without more, establish a breach of the systems duty.

Under section 7(2)(b) of the Coroners and Justice Act 2009, a jury is required where there is objective reason to suspect that a death resulted from an act or omission of a police officer. A self-inflicted death may also result from both the deceased’s conduct and police acts or omissions.

The claimant, the brother and next of kin of a man who died after jumping from a car park, sought judicial review of the coroner’s decisions that Article 2 was not engaged and that the inquest did not require a jury.

The deceased had mental-health difficulties and had recently been found on another car park roof. Police officers attended after a 999 call reporting agitated and distressed behaviour. They spoke with him, obtained some information, completed a vulnerable-person referral and allowed him to leave. He died shortly afterwards at a different car park.

A police professional-standards investigation identified several arguable missed opportunities, including failure to obtain further background information or seek mental-health advice. The issues were whether the claim was timely, whether the statutory no-substantial-difference test applied, whether the Article 2 operational or systems duty was arguably engaged, and whether section 7(2)(b) required a jury.

1. Permission and procedural issues. The claim was filed promptly or, alternatively, time would have been extended. The statutory no-substantial-difference provisions could not defeat the claim because the jury issue was binary: if the coroner had erred, the outcome would have been entirely different. Permission was granted on all grounds.
2. Operational duty. The low arguability threshold applies both to whether the operational duty exists and whether it was arguably breached when the decision is made before the evidence is heard. The coroner had applied, or appeared to apply, a higher and more definitive standard. The evidence provided a credible basis for arguing that the police knew or ought to have known of a real and immediate risk to life. Relevant matters included the reported behaviour on the roof, psychosis and auditory hallucinations, alcohol use, the recent comparable car-park incident, and the professional-standards findings.
3. The Rabone indicia were also arguably present. The officers had attended to protect the deceased, gave assurances, exercised some control, and could arguably have obtained mental-health assistance. The deceased was especially vulnerable and suicide during a psychotic episode was an exceptional rather than ordinary risk. The alleged failures to conduct checks, contact mental-health professionals and take further safeguarding steps therefore made an arguable breach of the operational duty.
4. The coroner also used an inapplicable causation approach. For Article 2 purposes, the question was whether the deceased lost a substantial chance of surviving because of the breach, which is a lower threshold than the tortious test.
5. Systems duty. This ground failed. The evidence showed that systems, policies and procedures existed. The alleged failings were individual lapses, and the suggestion that a senior officer’s attitude was widespread was speculative. That did not provide a real evidential basis for an arguable systems breach.
6. Jury. The statutory “reason to suspect” test is objective and low. The coroner again appeared to apply a higher, merits-based threshold. The evidence gave reason to suspect that police acts or omissions may have contributed to the death. A self-inflicted death is not excluded merely because the deceased’s own act was an immediate cause. The coroner’s decisions on Article 2 and the jury were quashed, and declaratory relief was granted.

The claim was a first-instance judicial review. It proceeded to a rolled-up hearing before the High Court after an order dated 21 March 2025.