Maguire, R (on the application of) v His Majesty's Senior Coroner for Blackpool & Fylde & Anor

Factual and Procedural Background

Individual A, an adult with significant physical and cognitive disabilities, had lived in a care home since the early 1990s. In April 2016 the local authority (“The Council”) issued a Standard Authorisation under Schedule A1 of the Mental Capacity Act 2005, lawfully depriving Individual A of liberty so that care-home staff could manage all aspects of her daily welfare, including medical decisions. On 21–22 February 2017 Individual A developed severe gastric symptoms that rapidly progressed to sepsis. Care-home staff, acting on clinical advice, decided not to transfer her to hospital on 21 February. She was eventually taken to The Hospital on 22 February but died that evening from a perforated gastric ulcer with peritonitis and pneumonia.

An inquest was opened. The Coroner ruled on 29 June 2018 that Article 2 of the European Convention on Human Rights (“ECHR”) did not require an expanded (jury) verdict because there was no arguable breach of the State’s substantive obligations to protect life. The family appealed. The present judgment is a concurring opinion agreeing that the appeal should be dismissed.

Legal Issues Presented

1. Whether, on the facts known or that ought to have been known on 21 February 2017, the State (through care-home staff and healthcare providers) owed and breached an operational duty under Article 2 ECHR to take preventive measures—specifically, to sedate or restrain Individual A and transfer her to hospital.
2. Consequently, whether the Coroner erred in concluding that Article 2’s enhanced procedural obligation was not engaged and that an expanded verdict was unnecessary.

Arguments of the Parties

The opinion does not contain a detailed account of the parties' legal arguments.

Table of Precedents Cited

Court's Reasoning and Analysis

Judge Stephens concurred with Judge Sales’ comprehensive judgment. The court reaffirmed that:

• The operational duty under Article 2 arises only where authorities know or ought to know of a real and immediate risk to life.
• On 21 February 2017 care-home staff and healthcare professionals did not possess, nor should they reasonably have possessed, knowledge of such a risk to Individual A’s life. Accordingly, the high Osman threshold was not met.
• The decision not to transfer Individual A to hospital on 21 February, although tragic in hindsight, did not constitute an arguable breach of either the operational duty or the separate systems duty.
• Because no arguable breach existed, Article 2’s enhanced procedural obligation was not triggered. The Coroner therefore acted lawfully in declining to require an expanded verdict.
• Judge Stephens cautioned against introducing a domestic “gloss” on the Strasbourg jurisprudence by substituting phrases like “particularly clear and pressing” for the established “real and immediate” test.

Holding and Implications

Appeal Dismissed.

The Coroner’s decision stands; no expanded Article 2 verdict is required. The ruling confirms the high threshold for engaging the State’s operational duty in healthcare settings and underscores that ordinary clinical negligence does not automatically invoke Article 2’s enhanced procedural requirements. No new precedent is set, but the judgment clarifies the correct application of existing Strasbourg principles within coronial proceedings.