“1. There was no evidence that the deceased died of external violence. 2. He appears to have died as a result of an overdose of Morphine combined with alcohol. There was no evidence of a recent injection site and the levels of the drug found are consistent with ingestion of Morphine or Heroin. The combined Morphine and alcohol have the effect of depressing the respiratory centres of the brain ….”
“6. In my opinion all the findings are in keeping with opiate intoxication through the injection of heroin being a significant contributory factor to death. The lack of demonstration of a needle puncture mark in no way excludes the most likely mode of administration of intravenous injection. Some issues could be clarified through further testing as described above. However the findings at present are consistent with the witness evidence which would appear to provide prima facie evidence that death has arisen as the result of administration of heroin through injection by a third party.”
“Information had been supplied to the police to suggest Michael had been injected with heroin shortly before his death by [A] and it is for this reason that he and the other occupants of the flat were arrested. The injection of drugs by one person into another is an unlawful act which, if it causes death, can lead to a conviction of manslaughter. Whilst the law on this point is by no means certain and has been heavily criticised, the case was investigated by the police to establish the possibility of prosecuting an offender on this basis. To do so it is necessary to place enough admissible evidence before a jury to satisfy them so they are sure that one or more defendants committed an unlawful act and thereby a conviction can follows. The girlfriend of [A] (Miss [D]) gave an account in interview whereby she states she saw [A] inject heroin into your brother. She has refused to make a statement to this effect or give evidence in support of a prosecution and therefore we cannot rely on her as a witness. In addition to this, she was using heroin on the evening in question and this taken together with factors I cannot disclose, makes her an unreliable witness. A witness [H] made a statement to the police in which he says [A] admitted to him that he had given your brother heroin. He does not say that he received an admission that [A] had injected heroin, but this is the inference he makes and the reason for the police investigation. [A] denies these issues which places the burden of proof upon the prosecution to prove this fact. [H] remains the only person capable of giving evidence on this crucial issue. There are a number of reasons why the evidence of [H] cannot be relied upon to prove an unlawful injection of heroin. 1. The two post mortems do no support the theory that heroin was injected. They have found no evidence of a site of injection. The conclusion drawn is that the level of drug found is consistent with ingestion of heroin and alcohol, as opposed to injection. 2. [H] does not state he received an admission regarding the injection of heroin. 3. [H] has certain features in respect of his history which for legal reasons I am unable to expand upon but which makes him an unreliable witness. 4. In your statement dated26 November 2001 you refer to the fact that [H] is now unwilling to give evidence without the support of others. There are no other witnesses who will agree to make statements or give evidence. 5. In addition to the above the police in their second investigation obtained evidence to be able to prove that your brother had taken drugs in the past and had been admitted to hospital in May 2000 during which he was treated for a drugs overdose. Whilst I appreciate that you have found it difficult to accept your brother may have taken drugs, the fact remains that there are reliable witnesses capable of and willing to give that evidence. In relation to the night of your brother’s death, there are no reliable witnesses to prove your brother was injected with drugs.”
“I confirm that I would be assisted in the conduct of this Inquest if the family of the deceased is legally represented.”
“19. This article expressly imposes a positive obligation on the state to protect everyone’s life. The state must take appropriate steps to safeguard the lives of those within its bounds. But the state’s obligation does not stop there. The European Court of Human Rights has held that by implication article 2 also requires there should be some form of effective official investigation when individuals have been killed as a result of the use of force: see McCann v. United Kingdom(1996) 21 EHRR 97 (the ‘death on the Rock’ case), and McKerr v. United Kingdom(2002) 34 EHRR 20 , para 111. The European Court of Human Rights has described this as a ‘procedural’ obligation imposed by article 2. The purpose of the investigation is to secure that domestic laws protecting the right to life are effectively implemented and, in cases involving state agencies, to ensure those responsible for deaths are made properly accountable: see Jordan v. United Kingdom(2003) 37 EHRR 2 , para 105. The requisites of an investigation, if it is to fulfil this procedural obligation inherent in article 2, were considered recently by your Lordships’ House in R (Amin) v. Secretary of State for the Home Department[2003] UKHL 51 ,[2003] 3 WLR 1169 .”
“The Lord Chancellor – (a) may by direction require the Commission to fund the provision of any of the services specified in Schedule 2 in circumstances specified in the direction, and (b) may authorise the Commission to fund the provision of any of those services in specified circumstances or, if the Commission request him to do so, in an individual case.”
“Paragraph 2 of Schedule 2 excludes the provision of advocacy services before coroner’s courts and most tribunals. Coroner’s courts are excluded because the inquisitorial nature of the process means that public funding for legal representation is not usually appropriate. … [If the financial eligibility requirements are fulfilled] I would consider funding if either there was a significant wider public interest in the client being represented at the inquest or if the following conditions applied: (i) the client is a member of the deceased’s immediate family (but if there are other family members some of whom are not financially eligible it may be appropriate to refuse funding or restrict it to a proportion of the costs of representation) and (ii) the circumstances of the death appear to be such that funded representation is necessary to assist the Coroner to investigate the case effectively and establish the facts. For most inquests, the Coroner will be able to carry out an effective investigation without the need for funded representation, but such representation may well be needed for inquests concerning agencies of the state. Any representations by the Coroner on this issue will be taken into account, but there is no requirement to seek the Coroner’s views before making an application.”
“As you may know, the latter test for funding arises from the need underECHR Art.2 to ensure that certain deaths are effectively investigated by the state. The European Court of Human Rights has considered the nature of this procedural duty arising under Art.2, and it is clear from the decisions of that court, including the decision in the case of Jordan to which you refer, that the duty of the state to carry out an effective official investigation of a death arises whenever a state agent is or may be responsible for the death or whenever the death occurred as a result of the use of force. I note here that responsibility for Mr Challender’s death does not appear to lie with the state. Nor does there appear to be any suggestion that the death arose from the use of force. Whilst I note your reference to an admission by a third party that he injected heroin into the deceased before he died. Even if that fact were true, it would not turn Mr Challender’s death into one that arose out of the use of force. In the circumstances, it appears that this case does not fall within the ambit of the Art.2 duty to investigate and there is no obligation on the state in this case to fund the family’s representation at the inquest. In any event, quite apart from the fact that this case does not appear to invoke the procedural duty arising under Art.2, there is no absolute duty to fund representation for the family of the deceased at the inquest. Whether funding for representation ought to be granted will depend on the facts of each case. As you know, your time in preparing for the inquest can be funded under Legal Help and this will ensure that your clients can participate in the inquest to an appropriate degree. It is only advocacy at the inquest that is an excluded service. Whilst I note that there will be a number of witnesses present at the inquest whom you would wish to cross examine on behalf of the family, I am not persuaded that the coroner him or herself will be unable to effectively examine those witnesses and establish the facts surrounding the deaths. I realise that this will be disappointing news for your clients, however, on the basis of the above, I consider that even if Mr Challender’s death did trigger the positive obligation to investigate under Art.2, funding advocacy services for your clients would not be necessary to discharge any duty to investigate effectively ….”
“22. In my view the answer lies in appreciating that the obligation to hold an investigation is an obligation triggered by the occurrence of a violent death. The obligation to hold an investigation does not exist in the absence of such a death. The obligation is consequential upon the death. If the death itself is not within the reach of section 6, because it occurred before the Act came into force, it would be surprising if section 6 applied to an obligation consequential upon the death. Rather, one would expect to find that, for section 6 to apply, the death which is the subject of investigation must itself be a death to which section 6 applies. The event giving rise to the article 2 obligation to investigate must have occurred post-Act. 23. I think this the preferable interpretation of section 6 in the context of article 2 ….”
“91. The duty to investigate is, in short, necessarily linked to the death itself and cannot arise under domestic law save in respect of a death occurring at a time when Article 2 rights were enforceable under domestic law, i.e. on and after2 October 2000 . 92. Such is the argument and to my mind it is irresistible ….”
“The obligation to protect the right to life under [article 2(1)], read in conjunction with the State's general duty underarticle 1 of the Convention to 'secure to everyone within their jurisdiction the rights and freedoms defined in [the] Convention', requires by implication that there should be some form of effective official investigation when individuals have been killed as a result of the use of force by, inter alios, agents of the State.”
“The Court notes that the first sentence of article 2(1) enjoins the State not only to refrain from the intentional and unlawful taking of life, but also to take appropriate steps to safeguard the lives of those within its jurisdiction. It is common ground that the State's obligation in this respect extends beyond its primary duty to secure the right to life by putting in place effective criminal law provisions to deter the commission of offences against the person, backed up by law-enforcement machinery for the prevention, suppression and sanctioning of breaches of such provisions. It is thus accepted by those appearing before the Court thatarticle 2 of the Convention may also imply in certain well-defined circumstances a positive obligation to take preventive operational measures to protect an individual whose life is at risk from the criminal acts of another individual.”
“69. The obligation to protect the right to life underarticle 2 of the Convention , read in conjunction with the State's general duty underarticle 1 of the Convention to 'secure to everyone within [its] jurisdiction the rights and freedoms defined in [the] Convention, also requires by implication that there should be some form of effective official investigation when individuals have been killed as a result of the use of force. The essential purpose of such investigation is to secure the effective implementation of the domestic laws which protect the right to life and, in those cases involving State agents or bodies, to ensure their accountability for deaths occurring under their responsibility ….”
“67. The obligation … requires by implication that there should be some form of effective official investigation when individuals have been killed as a result of the use of force …. The essential purpose of such investigation is to secure the effective implementation of the domestic laws which protect the right to life and, in those cases involving State agents or bodies, to ensure their accountability for deaths occurring under their responsibility.”
“Some form of effective investigation is, of course, needed where prisoners have been killed as a result of force by, inter alios, agents of the state: McCann …para 161. But, as the words 'inter alios' indicate, the obligation to safeguard the lives of prisoners is not confined to those who are at risk of the acts of state agents. It extends with equal force to all those whose lives are at risk from the criminal acts of another individual: Osman … para 115”
“69. … What form of investigation will achieve those purposes may vary in different circumstances. However, whatever mode is employed, the authorities must act of their own motion, once the matter has come to their attention. They cannot leave it to the initiative of the next of kin either to lodge a formal complaint or to take responsibility for the conduct of the investigative procedures. … 71. The investigation must also be effective in the sense that it is capable of leading to a determination of whether the force used in such cases was or was not justified in the circumstances and to the identification and punishment of those responsible. This is not an obligation of result, but of means. The authorities must have taken the reasonable steps available to them to secure the evidence concerning the incident, including inter alia eye witness testimony, forensic evidence and, where appropriate, an autopsy which provides a complete and accurate record of injury and an objective analysis of clinical findings, including the cause of death. Any deficiency in the investigation which undermines its ability to establish the cause of death or the person or persons responsible will risk falling foul of this standard. … 73. For the same reasons, there must be a sufficient element of public scrutiny of the investigation or its results to secure accountability in practice as well as in theory. The degree of public scrutiny required may well vary from case to case. In all cases, however, the next-of-kin of the victim must be involved in the procedure to the extent necessary to safeguard his or her legitimate interests.”
“24. Two and a half years had now elapsed since Naazish's death. By this time Mr Khan and his wife had withdrawn into themselves. Mrs Khan had effectively become a hermit, and Mr Khan was suffering from what was later diagnosed as a psychiatric illness. He did not open letters, and he allowed county court judgments to be entered against him by default as a consequence. He felt unable to deal with people. The junior post he now held with his firm did not involve this necessity, and his solicitor sometimes experienced difficulty and delay in obtaining instructions ….”
“69. … [U]nder our law it is the coroner's inquest, when it takes place, which furnishes the natural occasion for the effective judicial inquiry into the cause of a death that the Convention requires. The police investigation, in which the family played no part, and which culminated in a decision not to prosecute, could not act as a substitute ….”
“74. If the public judicial investigation required by Article 2 is to be an effective one … the inquest will not be an effective one unless Naazish's family can play an effective part in it. The evidence shows … that they are in no fit state to play that part themselves. Although the function of an inquest is inquisitorial, and in the overwhelming majority of cases the coroner can conduct an effective judicial investigation himself without there being any need for the family of the deceased to be represented, every rule has its exceptions, and this, in our judgment, is an exceptional case …. 75. In particular, the evidence is so complex that the coroner has enlisted the services of an independent medical expert to assist him. The Trust and its doctors and nurses will have the benefit of legal representation at public expense, and the family are likely to wish to explore the prospects of a verdict of neglect and/or a report by the coroner pursuant to Rule 43 of the Coroners' Rules. Mr Khan clearly could not manage this on his own.”
"I am not persuaded that the coroner … will be unable to effectively examine those witnesses and establish the facts surrounding the deaths"
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