Clarifying Coroners' Obligations under Article 2 ECHR: Insights from Parkinson v HM Senior Coroner for Kent [2018]

Introduction

The case of Parkinson, R (On the Application Of) v. HM Senior Coroner for Kent ([2018] EWHC 1501 (Admin)) presents a significant examination of the obligations of coroners under Article 2 of the European Convention on Human Rights (ECHR), particularly in distinguishing between systemic failures and ordinary medical negligence. This judgment addressed the circumstances surrounding the death of Mrs. Kathleen Parkinson, a 91-year-old woman who died in the Accident and Emergency (A&E) Department of Darent Valley Hospital on January 9, 2011. The primary parties involved were the Claimant, Gerard Parkinson (Mrs. Parkinson's son), the Dartford and Gravesham NHS Trust responsible for the hospital, and Dr. Sameer Hijazi, the A&E Department doctor on duty.

Summary of the Judgment

The High Court upheld the findings of the Senior Coroner for Kent, who conducted an inquest into Mrs. Parkinson's death. The Coroner concluded that the cause of death was "bronchopneumonia combined possibly with right lung pulmonary thrombi" and determined that there was no gross negligence or systemic failure on the part of the hospital or its staff. The Coroner found that Mrs. Parkinson was in the advanced stages of dying upon arrival and that any additional treatment would have been ineffective. Consequently, the Claimant's grounds for judicial review, which challenged the Coroner's findings on multiple bases including alleged breaches of Article 2, were dismissed.

Analysis

Precedents Cited

The judgment extensively referenced various case laws to delineate the scope of coroners' duties under Article 2 ECHR:

R (Humberstone) v Legal Services Commission [2010]: Highlighted the state's obligation to conduct effective investigations into deaths possibly involving state negligence.
R (Takoushis) v Inner North London Coroner [2005]: Emphasized the difference between general investigations and enhanced duties arising from systemic failures.
R (Middleton) v West Somerset Coroner [2004]: Addressed the breadth of inquests in cases where Article 2 is engaged.
Powell v United Kingdom (2000) and Rabone v Pennine Care NHS Trust [2012]: Discussed operational duties under Article 2 in the context of healthcare.
Lopes de Sousa Fernandes v Portugal (2017): Offered a recent authoritative interpretation of Article 2 obligations by the European Court of Human Rights.

Legal Reasoning

The court's legal reasoning centered on the distinction between the general duty to provide an effective legal framework for investigating deaths and the enhanced duty triggered by systemic failures or breaches of the state's substantive obligations to protect life. The judgment reaffirmed that:

Article 2 imposes both substantive and procedural obligations on the state.
The enhanced duty of coroners arises only in limited circumstances where there is an arguable breach of the state's obligations under Article 2, such as systemic failures.
Ordinary cases of medical negligence do not automatically engage the enhanced duty.
The coroner is best placed to determine whether Article 2 is engaged based on the evidence presented during the inquest.

In this case, the Senior Coroner found no evidence of systemic failure or gross negligence. The healthcare professionals acted appropriately given the circumstances, and Mrs. Parkinson was in the process of dying upon arrival. Therefore, the enhanced duty under Article 2 did not apply.

Impact

This judgment reinforces the framework within which coroners operate, particularly concerning the application of Article 2 ECHR in medical death cases. It delineates the boundaries of when an enhanced duty is triggered, thereby influencing future inquests and judicial reviews by emphasizing the necessity of systemic evidence before engaging heightened investigative obligations. Additionally, it underscores the importance of accurate and comprehensive evidence collection during inquests to support such determinations.

Complex Concepts Simplified

Article 2 of the European Convention on Human Rights (ECHR)

Article 2 protects the right to life, imposing both a negative obligation (not to take life unlawfully) and positive obligations (to protect life appropriately). In the context of coroners' investigations, this translates to ensuring that deaths are adequately investigated to determine causes, especially when state negligence is suspected.

Enhanced Duty of Investigation

An enhanced duty arises when there is a potential systemic failure or a breach of the state's obligations to protect life. This goes beyond individual cases of negligence, requiring a more thorough investigation into the circumstances surrounding the death.

Crooners' Justice Act 2009

This legislation governs the procedures for coroners in the UK, outlining their duties in investigating deaths, including when to issue reports or conduct additional inquiries to prevent future deaths.

Patient At Risk (PAR) Scoring and Manchester Triage System (MTS)

PAR scoring is an early warning system used to identify patients at risk of deterioration, prompting timely medical intervention. The MTS is a method used in A&E departments to prioritize patient treatment based on the severity of their condition. Clarity in these protocols is crucial to ensure appropriate medical responses.

Conclusion

The High Court's decision in Parkinson v HM Senior Coroner for Kent underscores the necessity for coroners to base their findings on robust evidence, particularly when determining the applicability of enhanced duties under Article 2 ECHR. By dismissing the Claimant's grounds for judicial review, the court affirmed that the Senior Coroner's findings were rational, well-supported, and aligned with established legal principles. This judgment serves as a critical reference point for future cases, reinforcing the structured approach required in inquests to discern between ordinary medical negligence and systemic failures warranting heightened scrutiny.