When the state may be implicated in someone’s death, there must be an effective official investigation into that death. This is so because of the provisions of Article 2 of the European Convention on Human Rights. This investigation will normally be at an inquest.

If there is no need for such an investigation, the inquest will normally only consider how the deceased came by his death in a very narrow sense: in effect, what killed him or her? If an “Article 2” style inquest is held, the wider circumstances of the death must be investigated. How broad should the investigation be – how far can or should the coroner go?

A recent High Court case concerning a death in custody, R (on the application of Lewis) v Mid and North Division of Shropshire Coroner and others [2009], emphasised that Article 2 does not require coroners to investigate matters over and above those that “bear a causal relationship to the death”. The coroner was entitled to refuse to allow the jury to address the fact that the prison officer who found the deceased hanging did not immediately enter the cell to provide assistance. It could not be said on the balance of probabilities that the deceased was still alive when he was found, so the officer’s actions could not be said to be causative of death – the coroner was therefore entitled to stop the jury from addressing the prison officer’s inaction. However, had the coroner decided to allow the jury to consider this issue, he would have been entitled to do so. This confirms that at the end of the day the scope of an inquest remains very much a matter for the individual coroner.