One of the common disputes that arises in inquests where there is a suggestion that a public body may have failed to take steps that could have prevented the death in question from occurring, is whether the inquest should be an Article 2 ECHR compliant Middleton inquest or a (at least in theory) narrower Jamieson type inquest. It is progressively being realised that, in many if not all cases, this is a dispute that is not worth having – and a recent illustration of this is the Administrative Court decision in R oao Kent County Council v HM Coroner for the County of Kent  EWHC 2768 (Admin). (Interestingly, one of the judges hearing the case was His Honour Judge Peter Thornton QC, the recently appointed Chief Coroner, who has also been part of the Court on three other recent inquest related judicial review cases – a very direct way of fulfilling that part of his role which requires him to provide guidance for coroners in England and Wales).
The Kent County Council case concerned the death of a 14 year old boy as a result of an apparently unintentional methadone overdose. In the nine months preceding his death, the boy’s parents had sought support from Kent County Council’s Social Services Department (SSD) to deal with a number of difficulties including their son’s abuse of drink and drugs. A Serious Case Review conducted after the death concluded there had been a number of shortcomings on the part of the SSD and “many missed opportunities”. It also concluded that there was a possibility that a different approach might have led to a different outcome.
Against that backdrop, the coroner determined that the inquest would be an Article 2 compliant Middleton inquest, as this was necessary for “effective public investigation by the inquest to satisfy the state’s obligation”. That ruling was challenged by Kent County Council and the challenge was successful. The Administrative Court accepted the argument that Article 2 was not, on the particular facts, engaged. This was first of all because the so-called
“general duty” under Article 2 had clearly not been breached. In relation to the so called “operational duty”, the court held that although the position of a vulnerable child in circumstances such as arose came within the “potential territory” of the operational duty, on a strict application of the test that the duty only arose when the public body was or should have been aware of a “real and immediate risk to life”, the duty did not in fact arise: it was insufficient for these purpose for there to have been a risk of harm, even a risk of significant harm, if that fell short knowledge of a risk to life.
However, what the court went to say suggests that in fact this did not matter very much. In the concluding paragraph of the judgment it suggested: “The extent to which the narrower form of inquest that will be required in the light of our decision would differ materially from a Middleton type inquest in this case is, perhaps debateable. [Counsel for Kent County Council] accepted that ultimately there may not be all that much difference in the scope of the inquest and which witnesses are called…” The court went on to emphasise that the coroner’s duty would be to investigate the facts “fully, fairly and fearlessly” which in the context might be read by the coroner as a signal from the court that although his ruling had been overturned, he was not to regard himself as being inhibited in the way he went about investigating what had happened.