The claimants sought judicial review of the rulings given by the defendant coroners in the course of the inquests following the claimant’s relatives’ deaths whilst in custody. The principal matter which fell to be determined in every case was whether the relevant inquest had complied with the procedural obligation imposed (implicitly) by Article 2 of the European Convention on Human Rights (right to life) for an ‘effective official investigation’ to be conducted into a death where ‘agents of the state are, or may be, in some way implicated’.

In the first case the claimant’s relative was found hanging dead in his cell. The coroner ruled that the jury could not consider questions relating to the actions of the prison service after the claimant’s relative had been found on the ground and that the jury’s role was limited to considering factual questions directly relating to the cause or contribution of death. The coroner held that because there was no evidence that the claimant’s relative was alive when found, any acts or omissions by the prison service thereafter could not have contributed to his death.

In the second case the claimant’s relative had set off his emergency cell alarm before hanging himself. The audible signal from the alarm panels had been disabled for some time and not repaired, and although the alarm light outside the prisoner’s cell was lit, the alarm was not answered for around 15 minutes and officers then attending had not had the necessary tool to cut the ligature from his neck. The coroner held that it was not for the jury to decide whether there was neglect or not. The coroner stated that the jury could make factual conclusions, but they could not be judgmental in respect of any acts or omissions or use words like “because” or “contributed to”.

In the third case, at the inquest the coroner had similarly directed the jury not to be ‘judgmental’ in their conclusions and that that they may produce only an objective narrative verdict.

The claimants contended, inter alia, that a jury had jurisdiction to consider facts that were not directly causative of death as to be otherwise restricted would be bound to prevent valuable and important comment about practices, procedures and omissions in prison as required by a proper investigation within the meaning of Article Art 2 ECHR.

The Secretary of State, as an interested party, submitted that the Art2 ECHR requirement to investigate a death was to be construed narrowly so that the only circumstance which was relevant to the death in question was one which bore a causal relationship to the death.

The claimants further argued that a coroner was not permitted to prevent a jury from reaching and recording findings of a factual nature, and that directing a jury not to use words such as “because” or “contributed to” wrongly inhibited them from making judgmental conclusions of fact central to the issues raised. It was also submitted that the coroner in the second case had erred in failing to leave the verdict of neglect as there was sufficient evidence to do so.

It was held that Art 2 ECHR was not prescriptive about either the precise scope or form of the investigation needed to fulfil the obligation nor the level of scrutiny required in respect of “non-causal” matters. There was no requirement under Art 2 ECHR that a jury reach factual conclusions on events that might cause or contribute to death in similar circumstances in the future. Compliance with the Convention did not require that the power of a coroner to alert the relevant person to take action where there was concern that future deaths might arise, pursuant to the Coroners Rules 1984 r.43, be exercisable by a jury applied.
The correct approach for the court to take, when considering whether the conduct of an inquest and a coroner’s directions satisfied the requirements of Art2 ECHR, was the narrow approach identified by the Secretary of State: the Secretary of State had disagreed with the Claimant’s core submission that Article 2 imposes an obligation to leave questions to the jury concerning factors that cannot be shown on the balance of probabilities to have caused or contributed to the death in question, suggesting that the conclusions be limited to causally relevant matters. The judge considered it inconceivable that an investigation into the cause of death would be inadequate for the purposes of Art 2 ECHR because its conclusions were limited to causally relevant matters. Accordingly, whilst a coroner had the power and might well consider it appropriate to conduct a wider ranging investigation than was required for the verdict, Art 2 ECHR did not require an investigation of, or expression of the conclusions upon, events and matters that neither caused or contributed to the death in question in order to render the inquest Art 2 ECHR compliant. The applications in the first and third cases were, accordingly, refused.

In the second case, the coroner’s directions had had the effect of preventing the jury from embodying judgmental conclusions of factual nature on a number of the disputed factual matters at the heart of the case. The inquest was not, therefore, an effective means for the proper discharge of the Art 2 ECHR obligation. The coroner had erred further in deciding not to leave the ancillary verdict of neglect to the jury as there was clear evidence of gross failures on the part of the prison and its staff which formed part of a clear and direct chain of causation leading or contributing to his death. The inquisition in that case was, accordingly, quashed and a new inquest ordered.