In the recently reported case of R (Silvera) v HM Senior Coroner for Oxfordshire [2017] EWHC 2499 (Admin), the Divisional Court looked at the investigative duties placed on the state by Article 2 of the European Convention on Human Rights and the importance of the coronial process in ensuring that those duties have been met. Specifically, the Court looked at the power of a coroner to resume a suspended investigation following other investigations and criminal proceedings. The Chief Coroner, before whom these judicial review proceedings were heard, found that the decision of the Senior Coroner for Oxfordshire not to resume an inquest following a criminal conviction for manslaughter was in breach of Article 2.

The judgment of the court was a reminder of the burden of the investigative duties placed on coroners by the European Convention on Human Rights even in cases where a death has been the subject of other investigations and proceedings. Although this case turned on its facts, it should give coroners good reason to consider more carefully whether to resume inquests after criminal proceedings and other investigations.

The Claimant’s mother, Ms Baker, died on or around 16 August 2012 in violent or unnatural circumstances and shortly after the Senior Coroner for Oxfordshire opened an inquest. In July 2013, the Claimant’s sister (“K”) pleaded guilty to the manslaughter of her mother on the basis of diminished responsibility and was detained in a secure mental health hospital. In July 2014 the Senior Coroner decided not to resume the inquest. He confirmed this decision in a letter to the Claimant’s solicitors in February 2016.

Both Ms Baker and K had a history of mental illness. They had been living together and were under the care of a community psychiatric nurse. In July 2012 K had been admitted to hospital under section 2 of the Mental Health Act 1983. She was transferred to a Psychiatric Intensive Care Unit but was then discharged by a consultant doctor, who had no prior knowledge of K, and moved on to an open ward. K absconded on 11 August 2012. Ward staff warned police that she was unwell and psychotic, that she had assaulted a member of staff, and that being out in public meant that she “might do something”. The police said it was the ward’s responsibility to locate K although they attended Ms Baker’s address for a welfare check. K told the police she would return to the ward but failed to do so. Ward staff warned that they were concerned about Ms Baker and also raised concerns about the welfare of their own staff if they tried to retrieve K. On 16 August 2012 Ms Baker was found dead in her property and K, who was still in the property, was arrested.

In addition to the criminal proceedings, there were two other investigations into the circumstances that led to the death of Ms Baker:

  1. The Oxford Health NHS Foundation Trust completed an internal ‘Root Cause Analysis Investigation Report’ of NHS care provided to K on 31 December 2012.
  2. In March 2014, the Oxford Safer Communities Partnership carried out a ‘Domestic Homicide Review’ under section 9 of the Domestic Violence, Crime and Victims Act 2004.

In his February 2016 letter confirming his decision not to re-open the inquest into Ms Baker’s death, the Senior Coroner stated that “a suspended investigation may only be resumed if the Coroner thinks that there is a sufficient reason to do so”. He stressed the discretionary nature of the coroner’s decision and stated that the test was “whether the facts of the death have been adequately aired”. He explained that he did not believe Article 2 applied and that, even if it did, the requirements of Article 2 had been satisfied by the Crown Court proceedings combined with the above two mentioned investigations.

In his judgment, the Chief Coroner found that the Senior Coroner had applied the wrong test. The test is found at Para. 8 of Schedule 1 to the Coroner and Justice Act 2009 where it states: “An investigation that is suspended under paragraph 2 may not be resumed unless, but must be resumed if, the senior coroner thinks that there is sufficient reason for resuming it”. The Senior Coroner therefore was required to consider whether there was a sufficient reason for resuming the inquest and there was no requirement for there to be exceptional circumstances.[1]

The Chief Coroner confirmed that Article 2 was engaged and that the investigations to date had not discharged the duty of investigation which was therefore triggered. It was relevant that the Crown Court had accepted a guilty plea so there had been no trial and the two investigations which had taken place had not been of a public nature and there had not been proper involvement of the family.

Although this case turned on the facts, it is a useful reminder of the importance of an inquest in ensuring the State has met its investigative duties in a situation where Article 2 is engaged. The public nature of an inquest and the involvement of family members are features of an inquest which enable this duty to be met even where the death has been investigated, arguably thoroughly so, in other ways.