Lewis, R (on the application of) v HM Coroner for Mid & North Division of the County of Shropshire & Anor

Factual and Procedural Background

This opinion concerns three linked judicial review applications and/or claims under the Human Rights Act 1998, referred to as JR1, JR2, and JR3. Each relates to rulings and directions made by coroners in inquests into deaths in custody of three deceased individuals, hereinafter referred to as the deceased in JR1, JR2, and JR3 respectively. The Defendants in each case are the respective Coroners, with the Secretary of State for Justice joined as an Interested Party. The three cases were ordered to be heard together, with JR1 as the lead claim.

In JR1, the Claimant is the father of the deceased who died by hanging in his cell at a young offenders’ institution. The inquest was held after a first jury was discharged due to juror connections. The Coroner ruled that the jury could not consider actions of the Prison Service after the deceased was found hanging, as there was no evidence he was alive at that time, limiting the jury’s role to factual questions directly related to the cause or contribution to the cause of death. The jury returned a verdict of suicide and made findings of failures by various authorities contributing to the death, but were not permitted to address post-discovery actions of prison officers.

In JR2, the Claimant is the mother of the deceased who died by hanging in a prison cell. The inquest jury was directed not to consider an ancillary verdict of neglect due to difficulties with causation. The jury returned a majority verdict of death by misadventure with a narrative verdict noting systemic failures including incomplete paperwork, disabled cell bells, and breaches of security.

In JR3, the Claimant is the mother of the deceased who died by hanging in a prison cell. The Coroner directed the jury that they must not be judgmental in their conclusions and must only record factual conclusions causative of death. The jury returned a verdict of suicide but stated they were unable to produce an objective narrative verdict.

Legal Issues Presented

1. Whether a Coroner in an Article 2 engaged inquest must allow a jury to consider and make findings on factors that did not cause or contribute to the death but are relevant to the circumstances of the death.
2. Whether the Coroner’s directions restricting the jury to non-judgmental, neutral conclusions and prohibiting certain language infringed the procedural obligations under Article 2 of the ECHR.
3. Whether the Coroner erred in refusing to leave the ancillary verdict of neglect to the jury.
4. Whether the investigative obligation under Article 3 requires the inquest to examine allegations of inhuman or degrading treatment unrelated to causation of death.
5. Whether the Coroner’s power to make Rule 43 reports suffices to discharge the Article 2 procedural obligation without the jury making findings on non-causal matters.

Arguments of the Parties

Claimants' Arguments

• The Coroner erred by limiting the jury’s consideration to only causative factors, thereby breaching Article 2 investigative obligations which require investigation of all relevant circumstances, including systemic failures and non-causal factors.
• Article 2 requires a broader interpretation of "how" the deceased came by death, encompassing "by what means and in what circumstances," including factors that may not have caused death but are relevant to the circumstances.
• The Coroner’s directions preventing judgmental conclusions and prohibiting words like "because" or "contributed to" unlawfully restricted the jury’s ability to make factual findings.
• The Coroner should have left the ancillary verdict of neglect to the jury, as there was sufficient evidence of gross failures contributing to the deaths.
• The Article 3 investigative obligation requires examination of inhuman or degrading treatment even if not causative of death.
• Rule 43 reports by the Coroner are insufficient alone to discharge Article 2 obligations; the jury should resolve factual conflicts and make findings on all relevant matters.

Defendants' Arguments

• Article 2 investigative obligations require investigation and findings only on matters causative or contributory to the death; the Coroner’s ruling limiting the jury’s scope to such matters was correct.
• The phrase "by what means and in what circumstances" should be narrowly interpreted to mean circumstances causally relevant to death.
• The Coroner’s directions were lawful and designed to prevent the jury from trespassing into civil or criminal liability while allowing factual, judgmental conclusions on causative matters.
• The refusal to leave the neglect verdict was correct due to insufficient evidence establishing a clear and direct causal connection between alleged failings and death.
• Article 3 investigative obligations are distinct and generally do not require inquest investigation; inquests focus on the cause of death.
• Rule 43 reports provide an appropriate mechanism for identifying systemic failings and preventing future deaths without requiring jury findings on all such matters.

Table of Precedents Cited

Court's Reasoning and Analysis

The court carefully analysed the statutory framework governing inquests, relevant domestic case law, and the jurisprudence of the European Court of Human Rights (ECtHR) concerning Article 2 procedural obligations. It distinguished between "Jamieson inquests" (pre-HRA or where Article 2 is not engaged) and "Middleton inquests" (post-HRA inquests where Article 2 applies), noting that the latter require a broader interpretation of "how" the deceased came by death to include relevant circumstances causative of death.

The court rejected the Claimants' submission that the jury must be allowed to consider and make findings on factors that did not cause or contribute to death but were merely relevant to the circumstances. It held that the investigative obligation under Article 2 requires investigation and factual conclusions only on matters causative or contributory to death, consistent with the statutory regime and Strasbourg jurisprudence. The court emphasised that the inquest is a fact-finding inquiry, not a forum for apportioning blame or determining civil or criminal liability.

Regarding the Coroner’s directions in JR2, the court found them to be erroneous in law for requiring the jury to use neutral, non-judgmental language and prohibiting the use of words such as "because" or "contributed to." This misdirection likely inhibited the jury from making proper factual, judgmental conclusions on central issues, undermining the effectiveness of the investigation under Article 2.

On the refusal to leave the ancillary verdict of neglect in JR2, the court concluded that there was sufficient evidence of gross failures causally linked to the death to justify leaving the verdict to the jury. The Coroner’s refusal was therefore erroneous.

In JR3, the court found the Coroner’s directions lawful and consistent with Middleton, properly limiting the jury to causative matters and allowing judgmental conclusions on those matters. The earlier non-judgmental direction was remedied by the summing-up, and the jury was properly informed of their role.

The court also rejected the Claimants’ argument that Article 3 investigative obligations require inquests to investigate non-causal allegations of ill-treatment, finding no logical or legal basis for such a requirement within the inquest procedure.

Finally, the court held that the Coroner’s power to make Rule 43 reports is an appropriate mechanism to address systemic failings and prevent future deaths, and that the jury is not obliged to make findings on all such matters.

Holding and Implications

The court’s final decision was as follows:

JR1 and JR3 claims are dismissed.

JR2 claim succeeds, the inquisition is quashed, and a new inquest is ordered.

The direct effect is that the inquests in JR1 and JR3 are upheld as compliant with Article 2 procedural requirements, while the inquest in JR2 was flawed due to erroneous jury directions and refusal to leave an ancillary verdict of neglect. The court did not establish new precedent beyond clarifying the proper application of existing authorities concerning the scope of jury findings and Coroner directions in Article 2 engaged inquests. Further submissions will be heard concerning the form of orders and any related applications in JR2.