Recent developments in coronial case law on Article 2 of the European Convention on Human Rights (ECHR) continue to define the scope of inquests and the obligations on public bodies. The High Court’s decision in R(AH) and R(IS) v Secretary of State for the Home Department [2025] EWHC 3269 (Admin) offers important clarification on when there is an arguable breach of the Article 2 “systems” duty such that the expanded scope of a Middleton inquest is required. This insight outlines the judgment, why it matters for organisations involved in inquests and how it could influence coronial scrutiny in practice.

The background

AH and IS brought judicial review proceedings following their detention at Brook House Immigration Removal Centre between July 2023 and March 2024. Both had a history of serious mental health difficulties and, during this period of detention, experienced deteriorating mental health.

Despite these risks, no Rule 35 reports were made and their detention was not formally reviewed. The claim challenged the lawfulness of detention on that basis, leading to the High Court’s judgment on 15 December 2025.

The High Court’s judgment

Article 2 of the ECHR requires public bodies to have appropriate systems in place to ensure that life is protected whereby it might otherwise be at risk. In R (Maguire) v Blackpool and Fylde Senior Coroner [2023] UKSC 20, the Supreme Court reiterated existing case law. The Court stated that in the area of healthcare provision, the systems duty operates at a high level and will only be found to have been breached in rare cases, with individual lapses in the operation of a system being insufficient to show a deficiency in the system itself.

The case of R(AH) clarifies that in order for the systems duty to be complied with, there must be evidence that the system is operating correctly. Individual errors to operate the system correctly will still not meet the threshold for a breach of the systemic duty. However, if there is evidence of a wide failure to implement or use the system, this should be interpreted as a breach.

Capsticks’ view: what is the effect of this judgment?

At inquest, we anticipate that this judgment will result in arguments that there is an arguable breach of the Article 2 systems duty when a system is insufficiently implemented at a local level. The mere existence of a system is less likely to be evidence that the systems duty has been met.

There may also be greater focus on what “the system” is: does this refer to the wider system of regulation and governance in place across the country – the “high” level referenced in Maguire – or does this refer to systems operating at a local level?

Public bodies involved in inquests should be prepared for coroners to scrutinise evidence around the working of the system and more closely examine whether the system is working, in order to make determinations as to whether Article 2 is engaged or not.

Public bodies should carefully audit and scrutinise their systems to ensure they are properly implemented and followed, with robust training in place. When employees report that systems are not fit for purpose, organisations should consider these reports carefully and ensure their systems are implemented properly – as this case has shown that the existence of the system is unlikely to be sufficient to demonstrate the Article 2 systems duty has been met.

How Capsticks can help

Capsticks has one of the largest inquest teams in the country, representing all types of service providers at around 1,400 inquests each year. We support organisations in managing the risks of inquests and providing advice on risk management. We also assist with reviewing and advising on policies, protocols and guidance to ensure that systems are robust and practicable. If your organisation has been informed that an inquest has been opened, Capsticks can help to protect your organisation’s reputation and give your staff the support they need throughout the entire inquest process, as well as assisting with submissions and advice on legal issues like those discussed in this insight.

If you have any queries around the issues discussed in this insight, or the impact of this judgment on your organisation, please contact Partner Georgia Ford or Associate Martha Froy from our Inquests and Advisory team to find out more about how Capsticks can help.