Self inflicted deaths in prison: “Something must be done” – but what?

Written by: Bridget Dolan KC
Published: 30 June 2017

R (Scarfe & Ors) v Governor HMP Woodhill & SoS Justice [2017] EWHC 1194 (Admin)

HMP Woodhill has achieved the unenviable status of having the highest rate and the highest number of self-inflicted deaths of any prison in the entire prison estate. Thirteen men have died there since 2013 at their own hand, seven of those in the last year. The eleven inquests that have recently been held in the Milton Keynes Coroner’s Court have produced several critical jury findings and a number of PFD[1] reports yet the alarming death rate has persisted.

It is unsurprising then that the families of some of the deceased, believing effective changes have not been made, turned to the High Court for action. They argued that the High Court should use its public law powers to ensure that the repeated failings noted in these successive cases were no longer tolerated.

The Woodhill Prison Governor and the Justice Secretary made it clear that they shared the great concern of the Claimants, the Court and other commentators (such as INQUEST who intervened in the proceedings) about the rate of suicides in prisons generally, and at HMP Woodhill in particular. The difficulty for the Claimants, however, was establishing the extent to which the identified problems at HMP Woodhill were capable of solution by means of their application for an order or declaration from the High Court.

Seeking Costs against Coroners

Written by: Bridget Dolan KC
Published: 19 June 2017

R (Gudanaviciene) v Immigration and Asylum First Tier Tribunal [2017] EWCA Civ 352

All humans make mistakes, Coroners included. Fortunately for any Coroner reading this, so long as you are merely human (and not flagrantly improper) and you don’t seek to defend your errors, then you should not be ordered to pay the successful applicant’s costs of reversing your poor judgment or bad decision-making.

The Court of Appeal considered whether a judicial body should be ordered to pay the costs of a successful application to judicially review its decision where it took no part in those judicial review proceedings.

Change the law to make Reports to Prevent Future Deaths work

Written by: Christopher Johnston KC
Published: 16 June 2017

The Grenfell Tower fire shows the need to give coroners’ recommendations more teeth.

On 28 March 2013 the coroner, after verdicts were returned on the deaths of six people in Lakanal House in 2009, made important and potential life saving recommendations (see for example her Letter to the Secretary of State for Communities and Local Government). These were made under then rule 43 – now the Coroners (Investigations) Regulations 2013 reg 28 and 29.

The government in over 4 years does not appear to have acted upon that report. Has the time not come to ensure that such vital recommendations are not ignored?

These coroner reports are usually made after an exhaustive review of the situation – and with the ability of all interested parties to make submissions. They are written after a review of the key issues undertaken with more forensic precision and over a far greater time than can usually be afforded by Parliament. Hence my “off the cuff” suggestion on Twitter that key coroner recommendations should be afforded a status akin to a negative statutory instrument: i.e. binding unless parliament overrules. This would force government to act and avoid life-saving issues being kicked into the long grass. In any event Parliament should act now to ensure coroners’ reports are not ignored in the future.

A death behind closed doors, but an Inquest in public

Written by: Jamie Mathieson
Published: 22 May 2017

R (T) v HM Senior Coroner for the County of West Yorkshire [2017] EWCA Civ 318

A young woman arrived at A&E with her mother. They were carrying a shoebox. Inside the shoebox was the body of a baby girl.

The baby’s mother, aged 19, had kept her pregnancy a secret and delivered the child alone, in her bedroom six days earlier. She said she never heard a cry and did not know whether the baby had been born alive. She hid the body in a shoebox under the bed. Three days later her mother had discovered the box. The women then kept the events from other family members and waited out the weekend before taking the body to hospital.

Examinations by a pathologist and specialist neuro-pathologist left the death unexplained: there was no identified natural disease or injury. Nor could they decide whether the baby was alive at birth. The CPS reached the view that there was insufficient evidence to charge anyone with a criminal offence. The woman’s initial allegation that her conception had followed a rape was withdrawn after police investigations revealed a consensual sexual relationship.

When the Coroner proposed to hold an inquest into her baby’s death the young woman brought a case to the High Court, arguing that the Coroner had no such power and that her identity should be kept anonymous. She lost decisively on both counts.

“the conduct of the Claimant was not in any sense a private matter”

Inquest representation: Is there a contractual right to “closure”?

Written by: Katie Gollop KC
Published: 4 May 2017

Shaw v Leigh Day (A firm) [2017] EWHC 825 QB

Attention family representatives! Absolutely nooo pressure at all, it’s just that if you don’t get your client the closure they want out of an inquest, now you can be sued for damages for causing them distress. That is the effect of this recent High Court decision.

The tweetie-birds-round-head inducing litigation saga is set out in more detail below. In a nutshell, Mrs Shaw’s elderly father had a cardiac arrest following complications of a trans aortic valve procedure (TAVI). She instructed Leigh Day, one suspects on a private basis (although this isn’t clear from the decision), and there was an Article 2 inquest at the end of which the jury concluded that the death was an unintended result of a therapeutic procedure and made no criticisms of anyone.

The inquest left Mrs Shaw dissatisfied and, so far as she was concerned, lacking answers to key questions. Even though there has been since been a successful negligence action against the hospital and the surgeon, the High Court has now cleared the way for her to claim £5,000 for mental distress from Leigh Day caused by what she says is the poor job they made of getting disclosure and representing her at the inquest.