Veronica Robinson, R (on the application of) v HM Assistant Coroner for Blackpool & Fylde

Article 2 applies automatically only where the circumstances fall within a category that necessarily gives rise, in every case, to a legitimate suspicion of state responsibility for breach of a substantive Article 2 duty. Death by misadventure following police involvement does not constitute such a category. The alternative question is whether the evidence discloses an arguable breach of the positive operational duty to protect life. The real and immediate risk test remains stringent, but the threshold for an arguable breach is lower.

An inquest summing-up need not rehearse evidence in forensic detail. A jury cannot be compelled to return a narrative conclusion, whether or not Article 2 applies. The duty to make a prevention of future deaths report arises only where the statutory criteria are met; deciding whether they are met is subject to rationality review.

The claimant, the mother of a man who died after being arrested by Lancashire police, challenged a jury’s inquest verdict of death by misadventure. The grounds alleged that the coroner wrongly held that Article 2 of the European Convention on Human Rights 1950 was not engaged, inadequately summed up the evidence, and unlawfully failed to make a prevention of future deaths report.

The inquest examined the police restraint, the deceased’s airway obstruction, the emergency response, relevant training and possible causation. The court had to determine whether the circumstances required an enhanced Article 2 inquest, whether the directions to the jury were legally adequate, and whether the statutory conditions for a prevention of future deaths report were satisfied.

1. Article 2. The claim that the circumstances automatically engaged Article 2 was rejected. The proposed categories of unnatural deaths involving police custody, swallowing a package, medical emergency or police use of force were too broad. Death by misadventure may be unpredictable, may involve no arguable state responsibility, and may require medical intervention beyond the expertise of state agents.
2. The coroner was therefore entitled to ask whether there was an arguable breach of the positive operational duty. The relevant test concerned a real and immediate risk to life, meaning a present and continuing risk, and required reasonable steps within the authorities’ powers. The test for the existence of the operational duty was stringent, but the question whether it was arguably breached involved the lower threshold of arguability. The coroner’s directions were imperfectly expressed but legally sound.
3. On the evidence, the officers acted reasonably in a rapidly developing situation and in accordance with their training. Although CPR might arguably have begun earlier, there was no sufficient basis for saying that reasonable steps within the officers’ powers had arguably been omitted or that the delay probably affected the outcome. The first ground failed.
4. Summing-up. The summing-up was adequate. The jury had heard and seen the evidence, were reminded of the material issues, and were not required to accept the expert evidence on restraint. The coroner ought to have made clearer whether a short-form and narrative conclusion could be combined, but the ambiguity was not materially misleading. A narrative conclusion was not mandatory, and no authority required the jury to return one. The second ground failed.
5. Prevention of future deaths report. Under Schedule 5, paragraph 7 of the Coroners and Justice Act 2009, the duty arose only if the coroner rationally considered that both statutory criteria were met. The coroner could infer a possible future risk but rationally concluded that he had not formed the view that action should be taken. His non-statutory letter of concern was therefore lawful. The third ground failed.
6. The claim for judicial review was dismissed. A fresh inquest would not have been justified in any event because the evidence was extensive, the cause of death was undisputed, and a fresh inquest was unlikely to produce new material facts.