This case was an appeal from unsuccessful judicial review proceedings held in the High Court.

In October 2004, Karl Lewis was sentenced to six years’ detention for a series of robberies and sent to YOI Stoke Health. While on night patrol on the night of 21 to 22 January 2005, Offi cer Knowles looked through the observation window in Mr Lewis’ cell and discovered that he had hanged himself from a light fi tting. Offi cer Knowles did not enter the cell. He had received no suicide prevention or fi rst aid training and was not equipped with a tool in common use in prisons, known as a fi shknife, which is designed to enable suicides to be cut down safely. Offi cer Knowles used his radio to call assistance; however, instead of using Code Red (signifying spillage of blood) or Code Brown (signifying the possibility of a loss of life), he radioed Code Blue, signifying breathing problems. As such, assistance took longer than it should have done to arrive. By the time Mr Lewis was cut down he was dead.

An inquest was held in October 2006. As part of proceedings, the coroner gave the jury a written questionnaire, the answers to which were incorporated in the verdict. The action taken after Mr Lewis was found hanging in his cell was not raised in the questionnaire. The jury was given no opportunity to express a view on it and the issue was also omitted from the coroner’s report. Mr Lewis’ father alleged, in the appeal, that this was an unlawful omission. It was submitted that for the jury’s verdict to be required on a fact or circumstance, it did not have to have been a probable cause of or contributor to the death, so long as it was capable of being such.

The Court of Appeal dismissed the appeal. It agreed that Article 2 of the European Convention on Human Rights required the state not only to abstain from taking life, but also to investigate impartially and diligently any death occurring at or in its hands. The omission in the report of the actions taken after Mr Lewis was discovered hanging in his cell was a breach of Rule 43 of the Coroners Rules 1984. In addition, it did see the force of the proposition made by Karl’s father: “that the circumstances of a death are not limited to its probable causes: they extend as a matter of plain English to the surrounding facts”. Lord Justice Sedley observed that “in a jurisdiction which is not concerned with the allocation of blame, potentially causative circumstances can be just as relevant as actually causative ones”. However, the Court of Appeal concluded that the present legislative allocation of functions between coroner and jury, properly interpreted and properly implemented, does fulfi l the functions, which the appellant correctly submitted, were required by the convention to be fulfi lled.

R (on the application of Keith Lewis) v HM Coroner for the Mid and North Division of the County of Shropshire and the Secretary of State for the Home Department [2009]