Pearson v HM Coroner for Inner London North [2005] EWHC 833 (Admin)

“It is correct that the scheme enacted by and under the authority of Parliament should be respected save to the extent that a change of interpretation (authorised by section 3 of the Human Rights Act 1998) is required to honour the international obligations of the United Kingdom expressed in the Convention. Only one change is in our opinion needed: to interpret ‘how’ in section 11(5)(b)(ii) of the Act and rule 36(1)(b) of the Rules in the broader sense previously rejected, namely as meaning not simply ‘by what means’ but ‘by what means and in what circumstances’.”

“ by inviting the jury’s answer to factual questions put by the Coroner….it would be open to parties appearing or represented at the inquest to make submissions to the Coroner on the means of eliciting the jury’s factual conclusions and on any questions to be put, but the choice must be that of the Coroner and his decision should not be disturbed by the Courts unless strong grounds are shown.” (paragraph 36) In Sacker he observed (at paragraph 28): “The inquest was not able to identify the cause or causes of (the deceased’s) suicide, the steps (if any) that could have been taken and were not taken to prevent it and the precautions (if any) that ought to be taken to avoid or reduce the risk to other prisoners. The most convenient and appropriate way to make good this deficiency is… to order a new inquest.”

“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. I think this is the preferable interpretation of section 6 in the context of Article 2. This interpretation has the effect, for the transitional purpose now under consideration, of treating all the obligations arising under Article 2 as parts of a single whole. Parliament cannot be taken to have intended that the Act should apply differently, to the primary obligation (to protect life) and a consequential obligation (to investigate a death). ”

“So the primary right to life conferred by Article 2 can have had no application to a person who died before the Act came into force. His killing may have been a crime, a tort, a breach of international law but it could not have been a breach of section 6 of the Act. Why then should the ancillary right to an investigation of the death apply to a person who died before the Act came into force? In my opinion it does not….I therefore agree with the opinion of Silber J in R (Khan) v. Secretary of State for Health [2003] EWHC 1414 (Admin) that the duty to investigate under Article 2 did not arise in domestic law in respect of deaths before 2 October 2002.”

“If Parliament had intended the rights under Article 2 to be split up, with the Act applying differently to the different aspects, then it would have provided for this expressly. The potential objections are obvious. It would be curious to give a right under the Act to an investigation of a killing to which the Act did not apply….the obvious conclusion is that the right to an investigation under the Act is confined to deaths which, having occurred after the commencement of the Act, may be found to be unlawful under that Act.”

“Plainly no Article 2 obligation to investigate McKerr’s death could arise under domestic law prior to 2 October 2000. But no more could it arrive after that date. It is a procedural obligation properly to be regarded as secondary or ancillary or adjectival to the substantive obligation to protect life, an obligation arising directly out of the loss of a life…..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 after 2 October 2000.”

“(1) The proceedings and evidence at an inquest shall be directed solely to ascertaining the following matters namely – (a) who the deceased was; (b) how, when and where the deceased came by his death; (c) the particulars for the time being required by the Registration Acts to be registered concerning the death. (2) Neither the coroner nor the jury shall express any opinion on any other matters.”

“(1) An inquest is a fact-finding enquiry conducted by a coroner with or without a jury to establish reliable answers to four important but limited factual questions…..the fourth question, and that to which evidence and enquiry are most often and most closely directed, relates to how the deceased came by his death. Rule 36 requires that the proceedings and evidence shall be directed solely to ascertaining these matters and forbids any expression of opinion on any other matter. (2) Both in section 11(5)(b)(ii) of the Act of 1988 and in rule 36(1)(b) of the Rules of 1984, ‘how’ is to be understood as meaning ‘by what means’. It is noteworthy that the task is not to ascertain how the deceased died, which might raise general and far-reaching issues, but ‘how…the deceased came by his death’, a more limited question directed to the means by which the deceased came by his death…. (6) There can be no objection to a verdict which incorporated a brief, neutral, factual statement; ‘the deceased was drowned when his sailing dingy capsized in heavy seas’, ‘ the deceased was killed when he was run down by an express train on a level crossing’, ‘the deceased died from crush injuries sustained when gates were opened at Hillsborough Stadium’. But such verdict must be factual, expressing no judgment or opinion, and it is not the jury’s function to prepare detailed factual statements….. (14) It is the duty of the coroner as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without to ensure that the relevant facts are fully, fairly and fearlessly investigated. He is bound to recognise the acute public concern rightly aroused where deaths occur in custody. He must ensure that the relevant facts are exposed to public scrutiny, particularly if there is evidence of foul play, abuse or inhumanity. He fails in his duty if his investigation is superficial, slipshod or perfunctory. But the responsibility is his. He must set the bounds of the inquiry. He must rule on the procedure to be followed. His decisions, like those of any other judicial officer, must be respected unless and until they are varied or overruled.”

“The inquiry is almost bound to stretch wider than strictly required for the purposes of a verdict. How much wider is pre-eminently a matter for the Coroner whose rulings upon the question will only exceptionally be susceptible to Judicial Review.”

“It is for the Coroner conducting an inquest to decide, on the facts of a given case, at what point the chain of causation becomes too remote to form a proper part of his investigation. That question, potentially a very difficult question, is for him. ”

“In short the inquiry must focus on matters directly causative of death and must, indeed, be confined to these matters alone (save only for ascertainment of the other specific details mentioned in rule 36(1)). The recent, eleventh edition of Jervis on Coroners puts it thus: ‘The question of how the deceased came by his death is of course wider than merely finding the medical cause of death, and it is therefore right and proper that the coroner should enquire into acts or omissions which are directly responsible for the death’.” (a) who the deceased was; (b) how, when and where the deceased came by his death; (c) the particulars for the time being required by the Registration Acts to be registered concerning the death. (2) Neither the coroner nor the jury shall express any opinion on any other matters.” ‘The question of how the deceased came by his death is of course wider than merely finding the medical cause of death, and it is therefore right and proper that the coroner should enquire into acts or omissions which are directly responsible for the death’.”

“It is my role, it is within my remit to determine matters that are directly causative to death but not to enquire into every underlying circumstances which may be thought of, however remotely, which may have responsibility for the death.”

“From the evidence we heard, Kelly certainly needed help but there is no evidence to suggest that all the professionals, or indeed the health care professionals, had done anything other than acted in good faith, professionally and tried to help her within quite difficult circumstances. Kelly died as a result of a drug overdose, by her own volition, which is very sad and tragic indeed. Clearly, no one who had any knowledge of this tragic death could not but have the deepest sympathy for Kelly’s mother who clearly was at the end of her tether trying to do the best for her. Her frustration was compounded by the unfortunate ‘cock up’ of the inappropriate warrant which then brought Kelly to London where she died. Kelly’s mother’s distress and, indeed, palpable anger, was entirely understandable, and the Court Services at the very least, owe her a big apology indeed. No doubt there will be an inquiry into this matter, which is entirely outside of the remit of my court and I shall comment no more and…..I wish them luck in their quest in seeking answers to address her concern.”