A prisoner had hanged himself after being left unsupervised in a single cell. He was a known suicide risk, but the Coroner directed the jury not to return a verdict which included any reference to lack of care.
Held: A coroner was free not to leave a lack of care verdict to the jury where a doctor had taken the decision which led to the death, in a case of suicide of a prisoner. He could do so despite the statutory prohibition on any verdict being framed in such a way as to appear to determine any question of liability.
Sir Thomas Bingham MR set out the coroner’s duty: ‘It is the duty of the Coroner, as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the relevant facts are fully, fairly and fearlessly investigated. .’ The court gave guidance on directions to be given by coroners on the lack of care verdict: ‘It is not the function of a coroner or his jury to determine or appear to determine, any question of criminal or civil liability, to apportion guilt or attribute blame . . the prohibition on returning a verdict so as to appear to determine any question of civil liability is unqualified, applying whether anyone is named or not. Much of the difficulty to which verdicts of lack of care have given rise appear to be due to an almost inevitable confusion between this expression and the lack of care which is the foundation for a successful claim in common law negligence . . it is to be hoped that in future the expression ‘lack of care’ may for practical purposes be deleted from the lexicon of inquests and replaced by ‘neglect’. Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide basic medical attention or shelter or warmth for someone in a dependent position (because of youth, age, illness or incarceration) who cannot provide it for himself. Failure to provide medical attention for a dependent person whose physical condition is such as to show he obviously needs it may amount to neglect . . Neglect can rarely, if ever, be an appropriate verdict on its own . . Neglect may contribute to a death from natural causes. Neither neglect nor self-neglect should ever form any part of any verdict unless a clear and direct causal connection is established between the conduct so described and the cause of death.’
Times 23-Jul-1993, Ind Summary 18-Oct-1993, Ind Summary 06-Sep-1993, Guardian 12-Jul-1993
Coroners Act 1988
England and Wales
Cited by:
Appeal from – Regina v North Humberside and Scunthorpe Coroner ex parte Jamieson CA 27-Apr-1994
The deceased prisoner had hanged himself. He had been a known suicide risk, and his brother said that the authorities being so aware, the death resulted from their lack of care. The inquest heard in full the circumstannces leading up to the death, . .
Cited – O’Reilly v Coventry Coroner QBD 3-Apr-1996
The inquest was said to have been flawed because relevant material was withheld from the jury, factual issues were not addressed, and the Coroner had refused to leave open the possibility of a verdict of lack of care or neglect. The deceased had . .
Cited – Takoushis, Regina (on the Application of) v HM Coroner for Inner North London and others CA 30-Nov-2005
Relatives sought judicial review of the coroner’s decision not to allow a jury, and against allowance of an expert witness. The deceased had been a mental patient but had been arrested with a view to being hospitalised. He was taken first to the . .
Cited – In re Catherine Lucy Clegg (an Application to Quash Inquisition on Inquest) Admn 2-Dec-1996
The father of the deceased sought an order quashing the inquest on her death. He had recorded a verdict of suicide. She had died from acute salicylate poisoning, an aspirin overdose. The hospital was said not to have recognised her condition and not . .
Cited – Parkin v HM Coroner for North Lincolnshire and Grimsby District Admn 23-Mar-2005
The family appealed against an open verdict. Her son was found hanged at school. The coroner felt unable to be sure that he had committed suicide. He had been looking forward to a new job as a theatre technician.
Held: There was evidence . .
Cited – Assistant Deputy Coroner of Inner West London v Paul and Another, Regina on the Application of CA 28-Nov-2007
The coroner appealed a judicial review granted after he allowed into evidence, hearsay evidence contained in a written statemnent from a witness who could not attend the inquest.
Held: Rule 37 does not allow the admission of a document, even . .
Cited – Regina v Davis HL 18-Jun-2008
The defendant had been tried for the murder of two men by shooting them at a party. He was identified as the murderer by three witnesses who had been permitted to give evidence anonymously, from behind screens, because they had refused, out of fear, . .
Cited – Hurst, Regina (on the Application of) v Commissioner of Police of the Metropolis v London Northern District Coroner HL 28-Mar-2007
The claimant’s son had been stabbed to death. She challenged the refusal of the coroner to continue with the inquest with a view to examining the responsibility of any of the police in having failed to protect him.
Held: The question amounted . .
Lists of cited by and citing cases may be incomplete.
Coroners, Prisons
Leading Case
Updated: 12 January 2022; Ref: scu.87445
