This case is concerned with the conduct of an inquest into the death of Ms Jacqueline Maguire [“Jackie”], aged 52, in hospital on 22 February 2017 from pneumonia and a perforated gastric ulcer and peritonitis and the impact upon this of article 2 of the European Convention on Human Rights (“the Convention”). Article 2 is a convention right set out in the Human Rights Act 1998 (“the HRA”). [1]
Article 2 provides, so far as is relevant, that “Everyone’s right to life shall be protected by law”. It is established law that this provision has a substantive aspect, governing the ways in which the state should act to protect life, and a procedural aspect, which imposes an obligation on the state to provide for investigation as to whether a death may have resulted from a breach of the substantive obligations imposed by article 2. The precise content of the substantive obligations and of the procedural obligation under article 2 varies depending on the circumstances of a particular case. In this appeal, both the substantive aspect and the procedural aspect of article 2 are in issue. [2]
The Coroner commenced the inquest into Jackie’s death on the basis that it was likely that article 2 would require an expanded verdict at its end, but recognising that in its course matters might be sufficiently ventilated and clarified so that article 2 would no longer require this. Jackie’s family were represented by counsel at the inquest, as were all the other interested persons. At the close of the evidence in the inquest hearing the Coroner invited submissions from the interested persons, including Jackie’s family, as to the form of verdict which the jury should be asked to return. In the light of those submissions, on 29 June 2018 the Coroner gave his decision that article 2 did not require an expanded verdict (“the verdict decision”). Therefore the jury was requested to give a short form verdict stating only the cause of Jackie’s death. Whether the verdict decision was correct in law is under challenge in these proceedings. [5]
a substantial body of domestic case-law has held that in relation to cases of arguable medical negligence in an NHS hospital, the enhanced procedural obligation does not apply and the state’s procedural obligation (in the form of the basic procedural obligation and the redress procedural obligation) is satisfied by a combination of the holding of an inquest to determine the cause of death, without any requirement of an expanded verdict, and the availability of a civil claim for damages for negligence: see eg R (Goodson) v Bedfordshire and Luton Coroner [2006] 1 WLR 432; R (Takoushis) v Inner North London Coroner [2005] EWCA Civ 1440; [2006] 1 WLR 461, paras 105-107 (“Takoushis”); R (Humberstone) v Legal Services Commission [2010] EWCA Civ 1479; [2011] 1 WLR 1460 (“Humberstone”), paras 55-67; R (Parkinson) v Kent Senior Coroner [2018] EWHC 1501 (Admin); [2018] 4 WLR 106 (“Parkinson”); and see the discussion in Morahan. [20]
instances of individual negligence should not be treated as indicating a breach of the systems duty, and it will be the coroner, as the decision-maker who examines the facts in detail, hears the evidence and has to decide what form of verdict should be given at an inquest, who is best placed and has the primary responsibility to decide whether an arguable breach of either duty has been established. [21]
The courts have been cautious about implying extensive positive obligations in the application of article 2 in the field of provision of medical services. [22]
Appeal dismissed [212 and 250]
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