ON APPEAL FROM THE HIGH COURT OF JUSTICE
SIR THAYNE FORBES SITTING AS A JUDGE OF THE HIGH COURT
Strand, London, WC2A 2LL
B e f o r e :
LORD JUSTICE RIMER
LORD JUSTICE ETHERTON
| REGINA on the application of KEITH LEWIS
|- and -
|HM CORONER for the MID AND NORTH DIVISION of the COUNTY OF SHROPSHIRE
- and -
THE SECRETARY OF STATE FOR THE HOME DEPARTMENT
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Mr Jonathan Hough (instructed by the Legal Department for Shropshire County Council) for the Respondent
Ms Jenni Richards and Mr Colin Thomann (instructed by Treasury Solicitor) for the Interested Party
Hearing dates: 9 & 10 December 2009
Crown Copyright ©
Lord Justice Sedley :
"(i) The information chain as to what information was passed along the process from Social Services to the Probation Service to the Court and to Stoke Heath Young Offender Institution.
(ii) The care which Mr Lewis received from his reception through to the night he died.
(iii) Cell sharing risk assessment both to others and himself.
(iv) The F2052SH procedure.
(v) The action taken after Mr Lewis was found hanging in his cell.
(vi) The Mental Health issues and how Mr Lewis was managed.
1. Do you agree that on Saturday 22nd January 2005 at about 1.20a.m. Karl Lewis was found in his cell on 'B' Wing of HMYOI at Stoke Heath?
2. Do you consider that:
a) Karl Lewis hanged himself intending to take his life or
b) Hanged himself or
c) Was found hanging
3. Was there a failure in the information Chain and, if so, did this cause or contribute to Karl Lewis's death? If so, please identify the same.
4. Should Social Services have kept in touch with Karl Lewis following his imprisonment and, if so, did this failure cause or contribute to Karl Lewis's death? If so please specify.
5. Should HMYOI at Stoke Heath have obtained further background information about Karl's history of self-harm at any time after his imprisonment on the 8th October 2004 and if so did this failure cause or contribute to Karl Lewis's death? If so please specify
6. Should the Probation Service have obtained further background information about Karl Lewis's history of self-harm and passed it to HMYOI Stoke Heath in response to the request from HMYOI Stoke Heath on the 11th October, 29th November and 24th December following the opening of each F2052SH and if so, did this cause or contribute to Karl Lewis's death? If so, please specify.
7. Should HMYOI Stoke Heath have referred Karl for a full Mental Health Assessment to an appropriately qualified Professional at any time prior to the 21st January 2005 and if so did this failure cause or contribute to Karl Lewis's death? If so please specify.
8. Should Karl Lewis have been transferred to the Health Care Centre on the 21st January 2005 and if so did this failure cause or contribute to Karl Lewis's death?
9. If not, should Karl have had more support on the wing than he was provided with? In particular should there have been more frequent observations? If so, did this failure cause or contribute Karl Lewis's death.
You must only answer the above questions if you believe that (either on its own or with others) that act or omission caused or contributed to Karl Lewis's death.
"Karl Lewis hanged himself intending to take his life, see questionnaire."
Findings about prison deaths
Prevention of similar fatalities
A coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the inquest is being held may announce at the inquest that he is reporting the matter in writing to the person or authority who may have power to take such action and he may report the matter accordingly.
Ought the coroner to have put the issue to the jury?
Sheriff's determination etc
(1)At the conclusion of the evidence and any submissions thereon, or as soon as possible thereafter, the sheriff shall make a determination setting out the following circumstances of the death so far as they have been established to his satisfaction—
(a) where and when the death and any accident resulting in the death took place;
(b) the cause or causes of such death and any accident resulting in the death;
(c) the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided;
(d) the defects, if any, in any system of working which contributed to the death or any accident resulting in the death; and
(e) any other facts which are relevant to the circumstances of the death.
As can be seen, paragraph (c) would evidently require the matters mentioned in §4 of this judgment to feature in a sheriff's determination on a prison death. And, as I have said in §16 above, it ought to have featured in the coroner's rule 43 report in Karl Lewis's case.
36. This will not require a change of approach in some cases, where a traditional short form verdict will be quite satisfactory, but it will call for a change of approach in others (paragraphs 30-31 above). In the latter class of case it must be for the coroner, in the exercise of his discretion, to decide how best, in the particular case, to elicit the jury's conclusion on the central issue or issues. This may be done by inviting a form of verdict expanded beyond those suggested in form 22 of Schedule 4 to the Rules. It may be done, and has (even if very rarely) been done, by inviting a narrative form of verdict in which the jury's factual conclusions are briefly summarised. It may be done by inviting the jury's answer to factual questions put by the coroner. If the coroner invites either a narrative verdict or answers to questions, he may find it helpful to direct the jury with reference to some of the matters to which a sheriff will have regard in making his determination under section 6 of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976: where and when the death took place; the cause or causes of such death; the defects in the system which contributed to the death; and any other factors which are relevant to the circumstances of the death. It would be open to parties appearing or represented at the inquest to make submissions to the coroner on the means of eliciting the jury's factual conclusions and on any questions to be put, but the choice must be that of the coroner and his decision should not be disturbed by the courts unless strong grounds are shown.
a) added a tenth question to the jury along the lines "Should OSG Knowles have been trained and equipped to intervene or secure assistance more rapidly?"; and
b) altered the final caveat to read: "You must only answer the above questions if you believe that (either on its own or with others) that act or omission could have caused or contributed to Karl Lewis's death".
Had this been done, the jury's answer would have formed part of the inquisition, as, it is contended, the law requires.
"the jury may, in addition to finding the direct or indirect causes or contributions to the death, also find facts relevant to the exercise of the coroner's power under rule 43."
This is likely to be more useful - as the House of Lords suggested in Middleton (§20) - where facts are disputed or uncertain. Indeed it may be in such cases that a finding by verdict is a desirable or even a necessary foundation of any rule 43 report. Here, perhaps unusually, the relevant facts were clear and undisputed.
Lord Justice Rimer:
Lord Justice Etherton:
"the competent authorities must act with exemplary diligence and promptness and must of their own motion initiate investigations capable of, first, ascertaining the circumstances in which the incident took place and any shortcomings in the operation of the regulatory system and, secondly, identifying the state officials or authorities involved in whatever capacity in the chain of events in issue": Öneryildiz v Turkey (2005) 41 EHHR 20 at para. 94; see also Trubnikov v Russia App No. 4979/99, 4 July 2005 at paras. 85 and 88."
"(5) An inquisition –
shall be in writing under the hand of the coroner and, in the case of an inquest held with a jury, under the hands of the jurors who concur in the verdict;
shall set out, so far as such particulars have been proved –
who the deceased was; and
how, when and where the deceased came by his death, and
"43 Prevention of similar fatalities
A coroner who believes that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the inquest is being held may announce at the inquest that he is reporting the matter in writing to the person or authority who may have power to take such action and he may report the matter accordingly."