In this case, the defendant coroner had carried out an inquiry into a person’s death.  The deceased had died in November 2009 at the age of 14 subsequent to drinking methadone.  He had been experiencing difficulties at home and school and had taken up drinking and drug abuse.  The claimant local authority had known about the deceased’s problems for nine months prior to his death and had tried to rectify the situation.  In September 2011, the coroner ruled that Article 2 of the European Convention on Human Rights applied to the deceased’s death and that the inquest should be held with a jury.  The local authority applied for judicial review of the coroner’s decisions.

The local authority argued that the coroner had erred in deciding that the inquest should be an Article 2 inquest, and that there had been no breach of the substantive obligation under Article 2 of the European Convention on Human Rights because the statutory systems for children in need of care had, at the relevant time, been in place and wholly adequate.  There had been no systemic failure that could have led to an arguable breach.  The local authority also argued that, even if Article 2 had been engaged, it had not applied since the local authority had done all  that it could by way of prompt and effective process to remedy any mistakes.  It also argued that the coroner’s reasons for making the Article 2 decision had been inadequate and that the decision to order a jury inquest had been made without proper grounds.

The court found that the coroner had been entitled to hold the inquest with a jury but decided to quash the coroner’s decision to hold an Article 2 inquest.  It was held: (1) In the nine months that the local authority had known about the deceased, it had known that his problems had become increasingly serious.  There had been a need for some action to be taken and it could be said in that regard that the claimant had failed.  However, even if the opportunities had been taken, there was no certainty, or even likelihood that the deceased’s death would have been avoided.  The deceased had been at risk but that had not been a risk to life.  The evidence did not justify the conclusion that any general or operational duty had been breached.  The coroner had been wrong to decide that the inquest had to be conducted as an Article 2 inquest.  (2) It had been within the coroner’s discretion to hold the inquest with a jury.  There was no evidence to suggest that the coroner had exercised his discretion improperly.  The coroner had been entitled to hold the inquest with a jury.