Prisoner's suicide - coroner directing inquest jury not to return verdict referring to neglect - state's investigative duty requiring inquest to culminate in expression of jury's factual conclusions as to by what means and in what circumstances death occurred

R (Middleton) v West Somerset Coroner and another: HL (Lords Bingham of Cornhill, Hope of Craighead, Walker of Gestingthorpe, Carswell, and Baroness Hale of Richmond): 11 March 2004

The deceased, a serving prisoner, killed himself after threatening to do so.

His family claimed that the prison service had failed to take appropriate steps to prevent him.

The coroner directed the inquest jury, under section 11 of the Coroners Act 1988 and rules 36 and 42 of the Coroners Rules 1984, that they should determine 'how' the deceased came by his death, without reference to neglect or attributing criminal or civil liability.

The jury returned a verdict of suicide, indicating failures of the prison services in a note to the coroner.

The claimant, the deceased's mother, sought judicial review of the coroner's refusal to append the note to the inquisition.

The judge concluded that the inquest failed to satisfy the state's investigative duty under article 2 of the European Convention on Human Rights.

The Court of Appeal (see [2002] Gazette, 10 May, 29); [2003] QB 581 allowed in part an appeal by the home Secretary.

The home secretary appealed.

Jonathan Crow and Rabinder Singh QC (instructed by Treasury Solicitor) for the home secretary; Hugh Mercer and Richard Eaton, solicitor-advocate (instructed by Clarke Willmott, Taunton) for the coroner; Ben Emmerson QC, Peter Weatherby and Danny Friedman (Howells, Sheffield) for the claimant.

Held, allowing the appeal in part, that to satisfy the investigative duty the inquest had to culminate in an expression of the jury's conclusions on the central issues; that under the existing regime that was not always possible and to that extent the scheme infringed article 2; but that, by reinterpreting 'how' in section 11 and rule 36 to connote 'by what means and in what circumstances' the death occurred, the jury could make the necessary factual conclusions to conform with article 2, while respecting the prohibition in rules 36(2) and 42 on extraneous expressions of opinion or attributing liability.