• The case of Speck has recently been published by the High Court.
  • The background issue related to the provision of a "place of safety" under mental health legislation.
  • In refusing permission, the Court re-emphasised that in Article 2 inquests, whilst the Coroner has a discretion to investigate matters which may possibly have contributed to the death, his only duty is to investigate those matters which cause, or at least arguably appear to have caused or contributed to, the death.
  • DAC Beachcroft acted for NHS England who were involved as the successor body for the former PCT


Case background

  1. Toni Speck ("TS") was detained by the police under s136 of the Mental Health Act 1983 ("the MHA"). The purpose of that detention was to take her to a "place of safety".
  2. A "place of safety" is defined under the MHA a including a hospital or a police station, amongst other places. 
  3. She was taken to a police custody suite. Unfortunately, whilst detained, she died. There was expert dispute as to whether the cause of death was excited delirium or serotonin syndrome.
  4. An inquest was opened and there were a number of pre inquest hearings. In the course of these, the family of TS invited the coroner to consider a number of issues relating to the use of the police custody suite as a place of safety including: whether the custody suite was appropriate, whether there were suitable arrangements between the police and NHS and whether funding for places of safety was appropriate.
  5. Mr Rawlinson, on behalf of NHS England, resisted extending the scope of the inquest in this way arguing that these matters related to political issues such as policy and resource allocation. In addition, he argued that such matters were too remote to meet the test for causation. 
  6. The Coroner accepted the arguments put forward by NHS England and refused to include those matters raised by the family as part of the scope for the inquest.
  7. It is that decision that the family judicially reviewed on the basis that it was disproportionate, perverse, procedurally improper and improperly determined. 

Court's judgment: Scope of Article 2

  1. ​The Court considered the relevant case law on the scope of an Article 2 inquest.
  2. At paragraph 28, Holroyde J stated "It is in my judgment clear… that a coroner conducting an article 2 inquest has a discretion to investigate matters which may possibly have contributed to the death, but his only duty is to investigate those matters which caused, or at least arguably appear to have caused or contributed to, the death."
  3. The argument made on the behalf of the family, that the Coroner should listen to the evidence before making a decision as to what to include, was rejected by the Court.

Court's judgment: Health-based place of safety vs alternatives 

  1. Between the death of PS and the inquest, a decision was made to establish a local "health based place of safety" ("HBPOS"). On behalf of the family, it was argued that there was a duty to provide a HBPOS and that the failure to do so was a material breach of that duty.
  2. The Court rejected the argument that there was a duty for a HBPOS to be available stating that whilst it may have been desirable, there was no duty to provide this. Both the local police station as well as the local Accident and Emergency department were designated places of safety and as such, given that a HBPOS did not exist, the police fulfilled their duty when they took TS to the police station.
  3. It was also argued that increased national concern about police stations being used as a place of safety meant that there was a duty on "the local emanations of the state" to provide a HBPOS. This argument was rejected as having not statutory or other legal basis.
  4. In light of its rejection of the above arguments, the Court ruled that "the claimant was … unable to show, even arguably, that the fact that there was no HBPOS at the material time of in itself evidence of a breach of duty, causative of or contributing to the death of [TS], which the coroner was required, or had a discretion, to investigate"
  5. Taking all matters into account, the Court found that the decision of the Coroner to refuse to expand the scope of the inquest to include consideration of HBPOS was a lawful exercise of his discretion.