“As we have seen in the present case our client was hospitalised on at least 20 occasions while in custody between Sept 03 – Sept 05. On many of these occasions her life was in danger. The real danger we submit gives rise to the investigate [sic] obligations placed upon the state to investigate the circumstances of our client’s repeated self-harm. A further imperative for such an investigation is the failure of the state to respond appropriately to the serious mental health problems that our client has had throughout her life, exacerbated we contend by her time in custody, and which were not treated appropriately. In all the circumstances we therefore contend that the SOS is obliged to hold a full public investigation into the treatment of our client between Sept 03 – Sept 05 while in custody.”
“I write to inform you that the Secretary of State for the Home Department has agreed to hold anArticle 2 ECHR compliant investigation into the case of [SP]. The investigation will be chaired by the Prison and Probation Ombudsman, Mr Stephen Shaw, and will meet the procedural obligations required byArticle 2 of the ECHR . The precise Terms of Reference, on which you will be consulted, will be set by Stephen Shaw but will broadly consider the care and treatment of [SP] whilst in custody at HMP/YOIs New Hall and Low Newton between 2003-2005 and her transfer to Rampton Secure Hospital… the appropriate scope of this investigation will be determined by the PPO in due course as the independent chair…”
“your inquiry into [SP’s] case must include, among other things: i) The inquiry must be held in public, save where there are Convention compatible reasons to hear the evidence of a particular witness, or other parts of the hearing in private ii) The inquiry must be capable of exercising a power to compel the attendance of witnesses iii) Subject to i) above, [SP’s] representative must be able to attend at public hearings of the inquiry and put questions to the witnesses in person iv) Her representatives must be given reasonable access to all relevant evidence in advance v) Adequate funding for [SP’s] representative must be made available without inappropriate conditions attached, and the funding must be at such a level as to allow her to be involved in the investigation procedure to the extent necessary to satisfy his [sic] legitimate interests.”
“1. The role of her local authority (Cheshire County Council) in relation to events leading up to and during her incarceration and their duties towards her as a “child in need”, “child at risk” and child in care, and 2. The role of the primary care trust and mental health trust in her home area, in addition to the role of each primary care trust (e.g. Pinderfield’s Hospital, Wakefield) and mental health trust connected to the prisons, covering pre-, during and post custody, and 3. The prison service and Youth Justice Board during her time in custody.”
“1. The management of SP by HM Prison Service, especially with regard to her life-threatening self-harming behaviour and in the light of the policies and practices applicable to SP at the relevant time; 2. Health issues contributing to and arising out of SP’s repeated self-harming in custody, including mental health assessments and SP’s clinical care by HM Prison Service, especially in the light of SP’s transfer to Rampton Secure Hospital; and 3. Whether, within the operational context of the Prison Service, any lessons in respect of policy and procedure can usefully be learned.”
“any inquiry would be patently incomplete if it is limited to the period when [SP] was in custody. It will be extremely difficult for the PPO to sensibly evaluate the facts before him without knowledge of the considerable background to [SP’s] situation and the full impact of this time on [her]. Any such inquiry is likely to be misleading and result in the PPO misdirecting himself”
“To conduct an Article 2 compliant investigation and report to the Secretary of State for Justice on the treatment of a young woman (SP) at HMP/YOI Low Newton and HMP HMP/YOI New Hall in 2003-2005. In particular: • To examine the management of SP by the Prison Service, especially with regard to her life-threatening self-harming behaviour, including consideration of how prisoners at risk of self-harm were cared for by the Prison Service at the relevant time; • To examine whether any changes in policy or procedures would have helped to prevent SP’s repeated self-harming during this time, or would contribute now to the safe care of prisoners exhibiting similar behaviour; • To examine relevant child welfare issues; • To examine relevant health issues (including mental health assessments) and assess SP’s clinical care up to the point of her transfer to Rampton Hospital; • To provide an opportunity to SP and her family to contribute to the extent they wish and is appropriate to an Article 2 complaint [sic] investigation.”
“…The Ombudsman will obtain SP’s Prison Service records and relevant policy documents and share them with SP, the Department of Health and the Prison Service as they become available. The Ombudsman will conduct interviews with relevant Prison Service [staff] and others. A written record will be produced for the interviewee to sign off. The Ombudsman will decide which evidence to make publicly available… [At the public oral hearing:] A person requested to give oral evidence may be represented during his or her evidence… Witnesses will be questioned by Counsel to the Investigation and the Ombudsman. Lines of questioning may, however, be suggested by the various parties. Once the evidence at the Investigation’s hearings has been concluded, the Investigation Chairman will invite Counsel to the Investigation and the representatives of the various parties to submit closing statements in writing. The Chairman will submit a report to the Secretary of State. Subject to any necessary redaction, the report will be publicised contemporaneously on the Ombudsman’s website.”
“On 8 and 9 July, they will be visiting HMPs New Hall and Low Newton respectively to hold a forum with staff who were responsible for SP’s care and/or played some part in it. Those attending will be invited to give an overview of what they did, how SP was, what she was doing and what was done for her. [They] will also look at what support was available for staff and how they felt. The forums will also help inform decisions about whom should be [sic] formally interviewed. Within the next three weeks or so we will share with you the documents we have collected so far…At this stage the sharing of information will merely be to ensure engagement all round and to enable you properly to contribute on lines of questioning.”
“It is proposed that all disclosure requests go through SCOP [Safer Custody and Offender Policy] who will maintain a central log of all documents and will deal with disclosure issues for the following reasons. As the investigation will involve two prisons and the DH [Department of Health], it is likely to involve a significant number of documents and therefore will be a complex co-ordination exercise. We propose that the liaison point in SCOP (currently Jenny Rees) should be your consultation point…resulting in significant savings to the public purse compared to D and ensuring that our disclosure obligations are fulfilled. I understand in D there were requests for a whole range of documents that were passed to TSol which were usually passed to SCOP to deal with and then all the documents passed back through TSol. We, like you, are trying to reduce legal costs and this seemed a circuitous way of handling disclosure requests. It is not of course for one minute contended that the Chair should not have access to all documents necessary to consider those questions under the Terms of Reference or that the Chair should be fettered in any way in his evidence gathering but it is necessary to set out the ground rules. This is not a Fatal Accident investigation. Here the obligations are different. You will have unfettered access to any documents you request, but where we have particular concerns about relevance, security, sensitivity or any other relevant concerns SCOP/TSol will need to liaise with you before the documents are disclosed to you. This is our general approach to disclosure at (article 2 compliant) inquests with which we consider article 2 compliant investigations have some parallels. With regards to disclosure by you of the documents to the parties, we trust that you will ensure that documents are disclosed to all parties simultaneously and as early as possible.”
“…we have not been furnished with any information as to the structure, purpose, issues, and questions to be raised or discussed, logistics and invitations, recording of information to be obtained, attendance of observers from the interested parties and the general method upon which these forums are based. We believe that this to be an [sic] highly unusual approach to attending witnesses and are firmly of the view that this approach may “contaminate” the witness evidence. We had been under the impression that the witnesses would be identified and a preliminary interview undertaken. We ask for clarification as to how these meetings will take place prior to the forums being held in order that we can review this fresh approach and make further representations prior to the forums occurring.”
“I am particularly concerned by your reference to the relevance of particular documents. This would be a matter for me alone, as Chair of the inquiry, to determine. I cannot imagine how it would serve the purposes of an independent and robust investigation if the Prison Service were to seek to advise me on relevance. It would certainly do nothing to assure SP, or her family and representatives, that the investigation was indeed Article 2 compliant. I find the notion frankly ludicrous.”
“Procedures This is an Article 2 investigation and must be conducted in an open, transparent and even-handed manner. You should assume that the material which you receive will be distributed simultaneously to the parties relevant to the investigation. However, the provision of any documents will be subject to a confidentiality undertaking and redaction where necessary, for example for security reasons or to comply with the Data Protection Act. Correspondence sent to or received from any of the parties should be copied to the other parties. Involvement of SP You must give SP, through her representatives and her family with her agreement, the opportunity to participate in your investigation. The SSJ will make adequate funding available to SP in order to allow her, and her family if appropriate to be involved in the investigation to the extent necessary to safeguard SP’s interests. Access to Witnesses You may undertake interviews with such witnesses as you deem relevant for the purposes of understanding the facts and circumstances that applied during the time outlined above. You should identify in advance those witnesses of fact who are, or were at the relevant times, employed by HM Prison Service that you intend to interview so that they can be offered support and representation if necessary. Those witnesses should be contacted in the first instance through a named contact point in Safer Custody and Offender Policy group, who will act as your liaison for this investigation. You are then required to provide the witnesses with a written explanation of your role, terms of reference and the purpose of the interview. Preliminary evidence gathering You will obtain SP’s prison records and seek access to her medical records and any other relevant documents, including local and national policy documents, through your named contact point in Safer Custody and Offender Policy Group. Chronology A chronology of events should also be prepared early in the investigation. This may be amended as the investigation progresses with the agreement of the parties. Advance disclosure of report and advance notice of criticisms Any person who may be criticised in your report must be given advance disclosure of the criticisms and be given the opportunity to respond before the report is finalised. You will submit your report in draft, with an executive summary, to the parties to allow for it to be checked for factual accuracy… Support to the investigator You may appoint an assistant investigator who must be sufficiently independent from the Prison Service and the named establishments in which SP was accommodated… The Department of Health will provide a suitably qualified health professional to undertake a clinical review of the case and to provide you with medical advice…”
“8. Before approving an application I would expect the Commission to be satisfied that either: there is a significant wider public interest, as defined by the funding code guidance, in the applicant being legally represented at the inquest; or funded representation for the family is likely to be necessary to enable the coroner to carry out an effective investigation, as required by Article 2, in line with the funding code guidance. 9. For most inquests where the Article 2 obligation arises, the coroner will be able to carry out an effective investigation into the death, without the need for advocacy. Only exceptional cases require the public funding of advocacy in order to meet the Article 2 obligation. In considering whether funded representation may be necessary to comply with the obligation, all the circumstances of the case must be taken into account, including: the nature and seriousness of any allegations which are likely to be raised at the inquest, including in particular any allegations against public authorities or other agents of the state; whether other forms of investigation have taken place, or are likely to take place, and whether the family have been or will be involved in such investigations; whether the family may be able to participate effectively in the inquest without funded legal representation. This will depend on the nature of the issues raised and the particular circumstances of the family. In most cases, a family should be able to participate effectively without the need for advocacy on their behalf. Legal Help can be used to prepare a family for the inquest; to prepare submissions to the coroner setting out the family’s concerns and any particular questions they may wish the coroner to raise with witnesses. 10. The views of the coroner, where given, are material though not determinative. There is, however, no expectation that the coroner’s views should be sought before making an application, or that the coroner will wish to express a view.”
“The investigation which Mr Payling is to carry out will be the first stage of the two-stage process envisaged in Ms Eagle’s letter to the Howard League….[W]hilst it is not intended that Mr Payling himself should hold public hearings, such hearings will be held during a further stage of the investigation. The individual who will be asked to carry out that second stage has yet to be appointed or identified, but it will be a person who is independent of the Prison Service, and we anticipate that it is likely to be person with relevant experience such as sitting as a deputy coroner. That person will be provided with Mr Payling’s report (which will also be made public) and I would anticipate that he or she will use the report as the starting point in deciding what areas require further investigation at public hearings, and what witnesses it is appropriate to call at such hearings. However, the person conducting the second stage of the investigation will be entitled to reach his or her own conclusions about the events in question, and will not be bound by what Mr Payling has said.”
“In this country…effect has been given to that duty for centuries by requiring such deaths to be publicly investigated before an independent judicial tribunal with an opportunity for relatives of the deceased to participate. The purposes of such an investigation are clear: to ensure so far as possible that the full facts are brought to light; that culpable and discreditable conduct is exposed and brought to public notice; that the suspicion of deliberate wrongdoing (if unjustified) is allayed; that dangerous practices and procedures are rectified; and that those who have lost their relative may at least have the satisfaction of knowing that lessons learned from his death may save the lives of others.”
“The duty to investigate imposed by article 2 covers a very wide spectrum. Different circumstances will trigger the need for different types of investigation with different characteristics. The Strasbourg court has emphasised the need for flexibility and the fact that it is for the individual State to decide how to give effect to the positive obligations imposed by article 2. In this jurisdiction every death calls for a certificate of the cause of death from a doctor or a coroner. In specified circumstances an inquest is required. These include where there is reasonable cause to suspect that the deceased died a violent or unnatural death, that the death was sudden and the cause unknown, or where the death occurred in prison. In further specified circumstances the inquest must be conducted by a jury. I have already described the nature of such an inquest where the death in prison was caused by suicide. Thus death requires a spectrum of different types of investigation, depending upon the circumstances of the particular case. This regime is part of the way in which the United Kingdom gives effect to the obligations of article 2. The regime makes no provision for a near-death by suicide. This appeal raises the question of how such an event is to be accommodated within the spectrum.”
“…The initial investigation should be prompt, so that the facts are investigated while the evidence is still fresh and the material witnesses are readily available to be questioned. If all such witnesses give their evidence readily, the course of events appears clear and the circumstances in which the attempted suicide took place are shown to involve neither a possible defect in the system for preventing suicide nor a possible shortcoming on the part of anyone in operating that system, the initial investigation may satisfy the requirement of efficacy without the need for further inquiry. In that event, if the prisoner who attempted to commit suicide or his representatives are appropriately involved in the investigation and a report of the investigation is published, the other requirements of an enhanced investigation may be satisfied.”
“In this case without in any way casting aspersions on Mr Sheikh’s integrity an investigation by a former prison governor could not have had the degree of independence required.”
“…It is not however apparent to the Court from the submissions of the applicant that this connection between the agencies and the Inquiry deprived it of independence. The chairman was, as is often the case in public inquiries, a senior member of the bar with judicial experience, while other members were eminent or experienced in the prison, police or medical fields. None had any hierarchical link to the agencies in question. It is not asserted that they failed to act with independence or that they were constrained in any way. They acted, as far as the Court can see, in an independent capacity and not as the employees or agents of the bodies whose fulfilment of their statutory duties was under consideration…”
“The Court finds no reason to doubt the independence of the officer appointed from outside the PSNI. It has not been substantiated that the method of appointment or the fact he reports to the PSNI deprives him of the necessary ability to report objectively and without being influenced by any officers implicated in the events.”
“The extent to which the requirements of effectiveness, independence, promptitude and expedition, accessibility to the family and sufficient public scrutiny apply will again depend on the particular circumstances of the case, and may well be influenced by the passage of time…Where the assertion or new evidence tends to indicate police or security force collusion in an unlawful death, the criterion of independence will, generally, remain unchanged. Promptness will be likely not to come into play in the same way, since, for example, there may be no urgency as regards the securing of a scene of the crime from contamination or in obtaining witness statements while recollections are sharp. Reasonable expedition will remain a requirement, but what is reasonable is likely to be coloured by the investigative prospects and difficulties which exist at such a late stage.”
“The Parole Board, which provided members of the DLP (Discretionary Lifer Panels) panels who sat on reviews of the applicant’s continued detention, was found in the…Weeks case (judgment2 March 1987 , Series A no 114)(para 62) to satisfy the requirements of independence, having regard not only to their manner of appointment but also to their functional independence from the executive. The Court notes that the applicant in this case criticises the fact that membership of the Board includes former prison service employees and previous members of Boards of Visitors, and that there are structural links between the Board’s secretariat and financing and the Prison Service. The Court is not persuaded that the presence on DLPs, which are presided over by a judge, of doctors or other qualified persons who have previous, relevant experience of work within prisons, for or in contact with the Prison Service, is sufficient to cast doubt on their independence or impartiality in their functions for the Parole Board. Nor does it perceive that their independence is undermined by the staffing or budgetary arrangements as described.”
“105…Lord Bingham (in Ullah) made two further points: first, that a national court “should not without strong reason dilute or weaken the effect of the Strasbourg case law”; secondly that, whilst member states can of course legislate so as to provide for rights more generous than those guaranteed by the Convention, national courts should not interpret the Convention to achieve this: the Convention must bear the same meaning for all states party to it. Para 20 ends: “The duty of national courts is to keep pace with the Strasbourg jurisprudence as it evolves over time; no more, but certainly no less”. 106. I would respectfully suggest that the last sentence could as well have ended: “no less, but certainly no more”
“17. The critical issue is whether the fair-minded and informed observer would conclude…that there was a real possibility that [the doctor] would not evaluate reports by other doctors who acted as EMPs objectively and impartially against the other evidence… 18.…Her relationship with the Benefits Agency was as an independent expert adviser. Her advice was sought and given because of the skills that she was able to bring to bear on medical issues in the exercise of her professional judgment. A fair-minded observer who had considered the facts properly would appreciate that professional detachment and the ability to exercise her own independent judgment on medical issues lay at the heart of her relationship with the Benefits Agency. He would also appreciate that she was just as capable of exercising those qualities when sitting as the medical member of a disability appeal tribunal. So there is no basis for a finding that there was a reasonable apprehension of bias on the ground that [the doctor] had a predisposition to favour the Benefits Agency.”
“…The nature and degree of scrutiny which satisfies the minimum threshold of an investigation’s effectiveness depends on the circumstances of each particular case. It must be assessed on the basis of all relevant facts and with regard to the practical realities of investigation work (see Velikova v. Bulgaria, no. 41488/98, § 80, ECHR 2000-VI, and Ülkü Ekinci, cited above, §144).”
“For an investigation into alleged unlawful killing by State agents to be effective, it may generally be regarded as necessary for the persons responsible for and carrying out the investigation to be independent from those implicated in the events. This means not only a lack of hierarchical or institutional connection but also a practical independence.”
“The investigation will be chaired by the Prison and Probation Ombudsman, Mr Stephen Shaw, and will meet the procedural obligations required byArticle 2 of the ECHR . The precise Terms of Reference, on which you will be consulted, will be set by Stephen Shaw but will broadly consider the care and treatment of [SP] whilst in custody at HMP/YOIs New Hall and Low Newton between 2003-2005 and her transfer to Rampton Secure Hospital… the appropriate scope of this investigation will be determined by the PPO in due course as the independent chair…”