The successful Claimant in the judicial review was the son of the deceased, and P’s brother. Following the incident, P pleaded guilty to manslaughter (on the ground of diminished responsibility). P had been sectioned under the Mental Health Act 1983 (MHA) a month before the incident, and was discharged from hospital only six days before the incident.

The coroner refused to resume the inquest following the conclusion of criminal proceedings. His reasoning being that the criminal proceedings, together with an internal ‘root-cause analysis’ investigation and report, and an externally-commissioned ‘Domestic Homicide Review’ constituted sufficient inquiry by the state.

The Administrative Court decision

It was held that sufficient inquiry had not taken place into the circumstances of the death, and hence that the investigative duty under Article 2 ECHR had not been satisfied.  Specifically, it was found that the fact that both the internal and external reviews were investigations held in private, with evidence not considered in public and tested, and limited participation by the family, could not satisfy Article 2.

What to take away

This decision is particularly significant for all providers of psychiatric care. 

The Administrative Court has confirmed that, where a death occurs in suspicious circumstances, internal or external reviews which are not fully independent, which do not involve families and hear contested evidence held in public, will not satisfy Article 2, and an inquest will be required. A criminal prosecution, certainly in circumstances where a guilty plea is entered before any trial, does not alter this position.

Accordingly, all such suspicious deaths will need initial referral to the coroner (as well as the police) and preparation will need to be made for a likely inquest in the future.  Such inquests are likely to be high profile, reported in the media, and require a number of both clinical and non-clinical staff to give live evidence.

How can Capsticks help

Capsticks is a market leader in the healthcare and inquest field and is ranked in the top tier for clinical negligence work by the Chambers Guide to the Legal profession and the Legal 500. We are also separately ranked in the top tier for mental health expertise. Therefore we are uniquely placed to assist providers with investigations and inquests, arising out of deaths following psychiatric detention and/or treatment.

If you would like to discuss the implications of this case further, or any other related cases or issues please contact: Philip HatherallTracey LucasIan CooperGeorgia Ford or Nicholas Lane.