When to Hold an Inquest

In England and Wales, an inquest must be held if there is reason to suspect:

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  the deceased has died a violent or unnatural death;

  
  
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  the cause of death is unknown; or

  
  
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  the deceased died whilst in custody or state detention.

An inquest may be held if the coroner believes that death may have been contributed to by neglect, failure of medical treatment, an otherwise natural death brought about by the deceased’s employment or a death where consideration of ECHR, art 2 arises.

In Ireland, the coroner is under a duty to hold an inquest if of the opinion that the death may have occurred:

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  in a violent or unnatural manner;

  
  
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  suddenly and from unknown causes; or

  
  
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  in a place or in circumstances which require that an inquest should be held by reference to any other enactment (this relates, essentially, to deaths in police, prison or military custody and industrial deaths).

An inquest may also be held where a medical certificate of the cause of death is not procurable and, following enquiry, it is not possible to ascertain the cause of death.

The Purpose of an Inquest

The purpose of an inquest is to answer four questions:

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  who died – the identity of the deceased;

  
  
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  where they died – the place of death;

  
  
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  when they died – time of death; and

  
  
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  how they died.

The answer to the first three is usually straightforward and does not require psychiatric expertise. ‘How the deceased died’, however, is a much more complex question and one in which psychiatrists are often involved as expert witnesses.

Inquest proceedings are inquisitorial. Their purpose is to assist the coroner in answering the above questions and to ascertain the truth about the death, not to apportion blame. The coroner leads questioning of witnesses.

How the deceased came by their death goes beyond the simple question of the medical cause. In R v HM Coroner for East Sussex Western District, ex p Homberg [1994] 1 WLUK 555, it was noted that although the word ‘how’ is to be widely interpreted, it means ‘by what means’, rather than in what broad circumstances. This ensures that the enquiry focuses on matters directly causative of death and is confined to these matters alone. This is also reflected in an Irish judgment:

However, in R v HM Coroner for Inner London West District, ex p Dallaglio [1994] 4 All ER 139, it was noted that:

Indeed, to limit it to the last link in the chain of causation would defeat the purpose of holding inquests at all.

Article 2, Jamieson and Middleton Inquests

There is a positive duty under ECHR, art 2 to protect life in certain circumstances, such as when the authorities knew, or ought to have known at the time, of the existence of a real and immediate risk to the life of an individual. This is known as the ‘operational duty’. The test for real and immediate risk is a risk which is more than remote or fanciful and which is present and continuing. Where there are questions around this specific issue, it is likely that a coroner will hold an ‘Article 2’ or Middleton inquest, so named after R (Middleton) v HM Coroner for Western Somerset [2001] EWHC Admin 1043 to distinguish it from a Jamieson inquest named after R v HM Coroner for North Humberside and Scunthorpe, ex p Jamieson [1995] QB 1. In Middleton, the involvement of the state arose when the inquest jury communicated to the coroner that an agent of the state, in this case the Prison Service, had failed in its duty of care to the deceased. The deceased had hanged himself in prison, and whilst he had been identified as at risk, the proper safeguards were never put in place. In an Article 2 case, the process is ‘a scheme in which limited issues are left to the jury, but a much wider power is given to the coroner, a professional adjudicator, to report on systemic failures’ (R (Lewis) v HM Coroner for the Mid and North Division of the County of Shropshire [2009] EWHC 661 (Admin)).

Jamieson and Middleton inquests are, or were, distinguished in terms of their remit: a Jamieson inquest had a narrow remit of determining by what means the deceased died; and a Middleton inquest had a wider remit of determining by what means and in what circumstances the deceased died. However, the remit of a Jamieson inquest has expanded so much that the Court of Appeal has recognised that, in terms of inquisitorial scope, there is now practically little difference between them. That the scope of an inquest is as wide as the coroner deems necessary is illustrated by R (Takoushis) v HM Coroner for Inner London North [2005] EWCA Civ 1440. The deceased, who had a long history of schizophrenia, was an in-patient. He failed to return from ground leave and later the same day he was seen preparing to jump from a bridge into the River Thames. He was taken to a nearby hospital, where triage established that he was at high risk of self-harm and needed attention within ten minutes. He was not seen as intended and left the hospital to jump to his death in the River Thames. The Court of Appeal held that although his case did not engage EHCR, art 2, there had not been a proper investigation as to whether a systemic failure had allowed the circumstances of his death to occur. The coroner was found to have failed to ‘investigate how the system was to work [after initial triage] and did not consider, for example, what was to be done and in particular what safeguards were in place if for some reason the patient could not be seen in the target time’. These are systemic issues which an expert psychiatrist should be prepared to address.

The Supreme Court, in Rabone v Pennine Care NHS Foundation Trust [2012] UKSC 2, decided that the operational duty under EHCR, art 2 applied not only to detained mental health patients, as established in Savage v South Essex Partnership NHS Foundation Trust [2008] UKHL 74, but also to non-detained mental health patients.

Since Middleton, there have been a small number of cases which illustrate other examples of state involvement. In R (Hurst) v HM Coroner for Northern District of London [2003] EWHC 1721 (Admin), the deceased was killed by a man known to be violent and potentially mentally ill and against whom he had given evidence in eviction proceedings. It was argued that the police and local authority could have foreseen the incident and that it was preventable, as both bodies were aware that Hurst was in danger from his eventual killer. In Osman v UK (23452/94) [1998] 10 WLUK 513, an individual was known to the police and education authorities to have been harassing and threatening students and their parents; he went on to kill one of the students’ parents and a teacher.