England and Wales High Court (Administrative Court) Decisions

Queen on the application of CLEO SCOTT Claimant v. HER MAJESTY'S CORONER FOR INNER WEST LONDO [2001] EWHC Admin 105 (13th February, 2001)

Neutral Citation Number: [2001] EWHC Admin 105

Case No: CO/2492/2000

IN THE SUPREME COURT OF JUDICATURE

QUEEN'S BENCH DIVISION

ADMINISTRATIVE COURT

Royal Courts of Justice

Strand,

London WC2A 2LL

Tuesday 13 February 2001

MR. JUSTICE PENRY-DAVEY:

1. This is an application by Mrs Cleo Scott the mother of Keita Michael Craig (the deceased) who died on 1 February 2000 in HM Prison Wandsworth for an order quashing the verdict of an inquest jury reached on 14 April 2000 concerning the death of the deceased.

2. During the evening of 30 January 2000 the deceased was arrested and charged with robbery, assault with intent to rob and possession of drugs, following an incident in the street. On the morning of 31 January 2000 he appeared at the Richmond Magistrates Court, and was remanded in custody for 2 days. The deceased's solicitor and his social worker Andrew Robotham had concerns for his well being and Mr. Robotham alerted his probation officer, Tracey Lowe. Ms Lowe sent a fax to the prison on a Prisoner Warning Notice expressing her concerns about the deceased's mental health problems and his attempt to harm himself at least once in the past. She said that his behaviour might be unpredictable, that he had expressed suicidal thoughts and tried to open his wrists in the cell with his teeth and nails. She added "Will be diverted to Wimbledon Magistrates Court Diversion Scheme for mental health assessment on Wednesday 2.2.00. Hospitalisation may be considered. Must see doctor and to be hospitalised". She also rang the prison and spoke to a deputy governor about her concerns.

3. Barbara Skilton, who worked for Securicor Custodial Services and was a custody officer at Richmond Magistrates Court at the time, completed a Self Harm At Risk Form (F2052SH) at 1pm on 31 January. In box 1 after the question "Why are you concerned?" she wrote "I have been alerted by the probation officer and the defendant's case worker that he has suicidal tendencies. He has already been diagnosed as being schizophrenic". In box 2 after the question "What does the prisoner say about his situation?" she wrote " He says that if he had anything sharp he would use it for self harm purposes. He is frightened he may harm himself." She added finally "He has been placed on a 15 minute watch and has had his shoelaces removed. He has been re-assured that there are no sharp objects that he can harm himself with in his cell." At 1.20pm he was placed in a cell with another inmate. When early that evening the deceased was taken to Wandsworth Prison, the form F2052SH accompanied him. At 7pm he was seen by the prison medical officer, Dr. Pothalingam. He read the form F2052SH and the self harm form filled out by Ms Lowe and he noted that the deceased was treated with fortnightly injections of depixol, with the next injection due the following day. He gave him a dose of chlorpromazine. On the form F2052SH he wrote "Known paranoid schizophrenic. Admit to HCC (Health Care Centre) and observe." In the medical notes he noted on examination that the deceased was still hearing voices. He said in evidence that he could have stated that the deceased was not to have any access to potential ligatures or sharp instruments but he did not do so. The examination it appears was very brief and took 5 to 7 minutes.

4. The deceased spent the night of 31 January - 1 February in a cell on his own and at some stage his shoe laces, which were long trainer laces, were returned to him. Nurse White was on duty and carried out what she described as frequent and intermittent observation of the deceased. There was no direction to keep him under special observation. On form F2052SH she made an entry relating to 7.15am on 1 February "Has not expressed any ideas of self harm. Settled and appears to have slept". During the afternoon of 1 February the deceased was seen by Dr Muthalali. He did not administer any injection of depixol, but it appears from the medical notes that the deceased told the doctor that his last injection had taken place 10 days before, which would have meant that he was not due any injection for some days. In any event, Dr Pothalingam had given him chlorpromazine and the evidence was that their effects were similar. The form contains two further entries, both by Staff Nurse Adedayo. The first entry timed at 8 pm read "Quiet and calm. Seen by the doctor. No self harm expressed." The final entry timed at 8.20pm read "Seen sitting on bed quiet." Mr Adedayo in his evidence at the inquest said that that was the last time he had seen the deceased alive and that he would have written that entry on the form at about 8.35pm. At about 8.45pm Nurse White checked the deceased's cell and found him dead, he having hanged himself by his shoe laces.

5. The inquest was opened on 7 February 2000. The substantive inquest was heard on 13 and 14 April 2000 before the coroner and a jury. There had been extensive pre-inquest disclosure of material together with discussion about proposed witnesses. A number of witnesses were called at the inquest, including those whose names I have mentioned with the exception of Dr Muthalali. No application was made in the course of the inquest for further evidence to be called. Before the summing up, the coroner discussed with counsel for the Craig family and counsel for the prison service whether or not he should leave to the jury a verdict of neglect, namely whether the cause of death was contributed to by neglect. The coroner referred to the leading authority of Regina v HM Coroner for North Humberside and Scunthorpe ex parte Jamieson 1995 QB 1 and concluded that there was no evidence on the basis of which it would be right to leave a verdict of neglect to the jury, a conclusion with which the solicitor for the family and counsel for the prison service agreed. When the coroner summed the matter up to the jury, he left three verdicts for them to consider, namely that the deceased killed himself, that he killed himself whilst the balance of his mind was disturbed, or an open verdict. The jury found the cause of death to be hanging, in that on Tuesday 1^st February 2000 at about 8.45pm the deceased was found hanged in his cell in the Health Care Centre at Wandsworth Prison. They said that the time of death was undetermined. Their verdict was that he killed himself whilst the balance of his mind was disturbed.

6. The first issue before the court is whether the jury should have been asked to consider a verdict with a component of neglect. Mr Simblet on behalf of the claimant submits that the deceased arrived in prison subject to F2052SH raised that morning, which contained clear concerns as to suicidal intent, and similar information was communicated to the prison by phone and fax by the probation service at the magistrates court, with some reference to the deceased's psychiatric background. He was placed initially in a shared cell and his shoe laces were removed. When he was first received at the Health Care Centre at Wandsworth Prison, he did not have his shoe laces. Whilst he was kept in the Health Care Centre there were no special instructions as to observation and his shoe laces were returned to him. Additionally it is submitted that the health care assessment required under the F2052SH procedure was not completed, and such examination as was carried out of the deceased was extremely cursory lasting about 5 minutes. The deceased was not given an injection of depixol and had stated an intention to hang himself. Finally there was evidence that he had been hanging for some time, namely that his body was cold and his jaw stiff. He submits that the information that the deceased was a paranoid schizophrenic, that his behaviour was unpredictable, that he was frightened of harming himself, and had tried to harm himself was all communicated to the prison, and that with the form F2025SH demonstrated a particularly high level of risk. During the brief medical examination the deceased said he was still hearing voices, which indicated unpredictable behaviour. Within about 24 hours having had his shoelaces returned he was dead. In those circumstances, Mr Simblet submits that the medical examination was so grossly inadequate as to constitute a failure to provide medical treatment to somebody who needed it, and, he submits , there was a clear and direct causal connection between that conduct and the cause of death.

7. The leading authority on neglect is Jamieson The facts of the case were as follows. The deceased was in prison serving a life sentence. He was recognised as being at risk of committing suicide. He had written to his mother to say that he did not wish to go on living and shortly thereafter cut his wrists and forearm. He survived but indicated that he wished he had been successful. He was transferred to the prison hospital and in due course to a single cell, although space in a shared cell was available. Night staff were given no instructions to keep any particular watch on him. In the morning he was found hanging. The coroner refused to leave the issue of neglect to the jury and the Court of Appeal held that he was right not to do so. Sir Thomas Bingham MR reviewed the statutory background and the authorities and set out general conclusions in these terms (at page 25A):

"(8) 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. Since many of those seeking that verdict do so as a stepping-stone towards such a claim the boundary is bound to become blurred. But lack of care in the context of an inquest has been correctly described as the obverse of self-neglect. 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."
(9) Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide or procure 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 that he obviously needs it may amount to neglect. So it may be if it is the dependent person's mental condition which obviously calls for medical attention (as it would, for example, if a mental nurse observed that a patient had a propensity to swallow razor blades and failed to report this propensity to a doctor, in a case where the patient had no intention to cause himself injury but did thereafter swallow razor blades with fatal results). In both cases the crucial consideration will be what the dependent person's condition, whether physical or mental, appeared to be.
(10) As in the case of self-neglect, neglect can rarely, if ever, be an appropriate verdict on its own. It is difficult to think of facts on which there would not be a primary verdict other than neglect. But the notes to form 22 in the Rules of 1984, although in themselves of no binding force, are correct to recognise that neglect may contribute to a death from natural causes, industrial disease or drug abuse. Want of attention at birth, also mentioned in the notes, may itself be regarded as a form of neglect. A verdict that, for instance,"the deceased died from natural causes [or industrial disease, or drug abuse] to which neglect contributed" would seem perhaps more apt than a verdict that "the deceased died from natural causes [or industrial disease, or drug abuse] aggravated by neglect," since "aggravated" in this context means "made worse," and in truth the neglect probably did not make the fatal condition worse but sacrificed the opportunity to halt or cure it.

(11) Where it is established that the deceased took his own life, that must be the verdict. On such facts, as the applicant in the present case accepted, there is no room for a verdict of neglect (or, as he would have put it, lack of care). It is also inappropriate in such a case, as the applicant also accepted, to describe that cause of death as aggravated by neglect (or lack of care). On certain facts it could possibly be correct to hold that neglect contributed to that cause of death, but this finding would not be justified simply on the ground that the deceased was afforded an opportunity to take his own life even if it was careless (as that expression is used in common speech or in the law of negligence) to afford the deceased that opportunity. Such a finding would only be appropriate in a case where gross neglect was directly connected with the deceased's suicide (for example, if a prison warder observed a prisoner in his cell preparing to hang a noose around his neck, but passed on without any attempt to intervene).

(12) 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."

8. On the facts of that case the Court of Appeal concluded that there was no doubt that the deceased took his own life and that was the only possible verdict. The jury could not properly have found that neglect (or lack of care) contributed to or aggravated that cause of death even if all the disputed facts were resolved in favour of the applicant. At its very highest, the applicant's case suggested that the doctors and the prison authorities gave the deceased an opportunity to take his own life. The case could not support a verdict that neglect contributed to the suicide of the deceased.

9. Mr Simblet relies additionally on Regina v HM Coroner for Coventry ex parte O'Reilly (1996) COD where this court held that there should be a new inquest with consideration being given to the question of neglect, where there was new evidence (which had not been investigated at the inquest) which could support a different verdict; and that in the circumstances it was necessary and desirable in the interests of justice that the inquisition be quashed and a new inquest held. Further he relies on Regina v HM Coroner for Swansea ex parte Chief Constable of South Wales (2000) 164 JP 191 where the police sought judicial review of an inquest verdict on the basis that there was no evidence on which the jury were entitled to find neglect and that the issue should not have been left to them. There the deceased, a young man with a drug problem, was found slumped in the street having seemingly taken drugs and consumed alcohol. He was searched briefly but bottles of dihydrocodeine and codeine phosphate issued that day were not found during the search, and when subsequently discovered in his jacket were found to have substantial numbers of tablets missing. This court held that there was evidence in the circumstances of that case on the basis of which the verdict containing neglect could have been left to the jury because:

(1) a failure to search could amount to a failure that was gross;

(2) a failure to rush the deceased to hospital could have been a failure that was gross;

(3) a failure by the police surgeon to detect that the detainee was suffering from multiple drug poisoning could be described as gross;

(4) a failure to act on information highly relevant to the deceased's condition on the police national computer printout could amount to a failure that was gross;

(5) a failure during the night to procure any effective medical treatment could be described as gross.

10. Mr. Simblet submits that the defaults in the instant case have the same character as those in the Swansea case, in that in each there was a failure to act on highly relevant information, and to take obvious steps. This deceased it is submitted presented a very high risk which had been identified and communicated to the prison. He presented an acute risk of suicide and was understood by all involved to suffer from paranoid schizophrenia; his shoe laces had been identified as a means by which he might kill himself. Further he submits that the test for causation identified in Jamieson namely that there is a "clear and direct causal connection" is met in that the deceased was known to be mentally ill, was expressing suicidal ideas, and preventive measures had been taken by removal of his shoelaces. The timescale within which the death occurred was an extremely short period and the restoration of his shoe laces and failure to keep the deceased under proper observation resulted in his death. He submits that in all those circumstances the coroner was wrong not to leave neglect for the jury's consideration, despite the course of events at the inquest.

11. Mr. Burnett QC on behalf of the coroner submits that none of the failures alleged amounts to neglect as defined in Jamieson. He submits that none comes close to the example given by the Master of the Rolls in Jamieson necessary to attach "neglect" to a verdict of suicide. He suggests that the claimant faces insuperable difficulties in showing that the deceased was in obvious need of medical attention and that there was a gross failure to provide or procure it, and he submits that three of the four alleged failings cannot be said to be a clear and direct cause of the death, namely the failure to continue a 15 minute watch, the failure more generally to watch the deceased sufficiently, and the failure to give him a depixol injection. Even if it can be said that the deceased was provided with an opportunity to kill himself as a result of the various decisions taken by the prison staff, Mr. Burnett submits that their failings were not directly connected with the suicide in the sense necessary to found a verdict of neglect. He submits that the coroner was right not to leave a verdict incorporating neglect to the jury.

12. Mr. Morton on behalf of Her Majesty's Prison Service also submits that none of the failings alleged whether separately or together would have enabled a properly directed jury to return a verdict incorporating neglect. As to the alleged failure to heed warnings about the risk that the deceased might commit suicide and the returning of his shoelaces to him, Mr. Morton submits that the medical staff applied their minds to the deceased's condition and concluded that he did not appear to be at risk of suicide. They reached he submits a reasonable but erroneous conclusion which is very different from a failure to provide or procure basic medical attention. As to the deceased's medication and the failure to prescribe depixol, it is submitted that there was good reason for the medication not being administered on 1 February in that when the deceased saw Dr Muthalali he told him that he had had the previous injection 10 days earlier, which would have meant that no further injection was due for some days. In any event it is submitted that that issue is irrelevant to the question of the appropriate verdicts to leave to the jury because the evidence was that chlorpromazine which was prescribed on 31 January had a similar action to depixol and a delay of 24 hours in administering depixol would not have made any difference to the deceased's behaviour or demeanour. As to observation, Mr. Morton submits that any failure to keep the deceased under frequent observation afforded him at most an opportunity to take his own life (an opportunity with which he would have been presented in any event even if he had been watched every 15 minutes) and would provide no evidence for a verdict incorporating neglect.

13. In my judgment the submissions of the claimant that a verdict incorporating an element of neglect should have been left to the jury are well founded. It is pointed out that the solicitor for the family when pressed by the coroner did not seek such a verdict, but, the proceedings being inquisitorial in nature, it was for the coroner to decide whether there was evidence fit to be left to the jury in respect of such a verdict. In my judgment he was wrong in concluding that there was no such evidence. The deceased was known to be a paranoid schizophrenic, to have expressed the intention to commit suicide and to have tried to harm himself. In the light of that, preventive measures had been taken in that his shoelaces were removed. When Dr Pothalingam examined the deceased he noted that he was still hearing voices. Against that background at a later stage his shoelaces were returned and no special observation was directed. It was those shoelaces that he used to take his own life. The illustration given in Jamieson by the Master of the Rolls of the mental nurse observing that a patient had a propensity to swallow razor blades and failing to report the propensity to a doctor in a case where the patient had no intention to cause himself injury but did thereafter swallow razorblades with fatal results is in my judgment an illustration similar in principle to the course of events in this case. The restoration of shoelaces to the deceased combined with the failure to keep the deceased under proper observation resulted in his death, and in my judgment there was evidence of a gross failure to provide medical attention where the mental state of the deceased obviously called for such attention.

14. There was also in my judgment evidence of a clear and direct causal connection between that conduct and the cause of death. In Regina v HM Coroner for Coventry ex parte Chief Constable of Staffordshire Police 164 JP 665 the deceased was an alcoholic who was arrested and detained at the police station. He was initially too drunk to interview. The police were informed by the family that he would probably have the shakes. No doctor was called. The following morning he spilled two cups of tea by reason of his shaking hands. He was allowed into an enclosed exercise yard and fell. The fall led to convulsions and his eventual death. This court considered the meaning of "clear and direct causal connection". Tomlinson J said this (at 675G)

"The key to the proper approach here is, in my judgment, an appreciation that the expression "clear and direct causal connection" was not used by the Master of the Rolls in the Jamieson case in the same sense in which such words might be used when considering whether a breach of contract or a tort has caused recoverable damage, or, perhaps most pertinently when considering whether the cause of a loss is to be found within a list of insured or excluded perils in a policy of insurance. If, for example, I were directing myself by reference to the principles enunciated by the House of Lords in Leyland Shipping Company Ltd v Norwich Union Fire Insurance Society Ltd (1918) AC 350 as appropriate when considering questions of causation in relation to a policy of marine insurance, I do not think that it would occur to me to conclude that the death of the deceased had here been caused by any conduct of the police. For the avoidance of doubt I should emphasise that any view I express in this connection could not be of any relevance in any proceedings which may hereafter be brought as between the parties presently before me. The parties have not argued, and I am not concerned to decide, any questions which have any bearing on the establishment of liability for the death of the deceased. I make the point, however, to emphasise that the causal connection which is relevant in the context of consideration by an inquest jury of the addition of a neglect rider is, in my judgment, not the same as the causal connection for which one may look in the context of other, perhaps more familiar, enquiries. The touchstone in the present context is, I believe, the opportunity of rendering care, in the narrow sense of that word, which would have prevented the death. (see again per Croom-Johnson LJ in the Hicks case at page 1633). That does not mean that a conscientious person would necessarily have done that which would have successfully prevented death. The question is whether he had the opportunity of doing something effective."

15. I respectfully agree with that interpretation of the words used by the Master of the Rolls in Jamieson and accordingly in my judgment there was here evidence of a clear and direct causal connection between the conduct of the prison authorities and the cause of death. It is pertinent to add that this case lays down no new issue of principle; it does involve the application of principle set out in Jamieson to the particular and materially different facts of this case.

16. Mr Simblet further submitted that there was an insufficiency of inquiry at the inquest in that witnesses whose evidence may have been relevant to the issue of neglect were not called. In the light of my conclusion on his main submission on whether the issue of neglect should have been left to the jury, it is not necessary to consider the further submission and I express no view on it.

17. I go on to consider the question of the appropriate relief if any in this case. In Regina v Inner South London Coroner ex parte Douglas Williams (1999) 1 All ER 344 the Court of Appeal held that the test for the court to apply when deciding whether in the exercise of its discretion it should grant relief when a coroner had failed to leave a possible verdict to the jury was whether it was necessary or desirable to do so in the interests of justice. The claimant submits that if the issue of "neglect" should have been left to the jury and was not, then, if the family seek a new inquest it is "necessary or desirable in the interests of justice to have a new inquest." The claimant expresses in her statement her determination that the matter be addressed and submits that a "neglect" verdict has an important role to play. She relies on the words of the Master of the Rolls, Lord Woolf in the Douglas Williams case (at page 348a) as to the importance of the role of the inquest: "In particular where someone dies in custody, as here, an inquest can provide the family with the only opportunity they will have of ascertaining what happened. In addition, as Mr. O'Connor contends, an inquest's verdict can have a significant part to play in avoiding the repetition of inappropriate conduct and in encouraging beneficial change." In my judgment the views of the family including the consideration that they may have been deprived of the comfort and consolation of a verdict incorporating neglect are to be taken in to account, not as a determinative factor but as a significant factor among a number of others. It is not suggested in this case that there is any particular reason (for example, unavailability of witnesses) for not ordering a new inquest, nor is it suggested that there has been such a lapse of time since the death that a new inquest would be difficult or impractical. I do take into account the fact that if there is a further hearing witnesses will have to undergo the ordeal of giving evidence again about a traumatic and distressing event, but in my judgment in all the circumstances of this case and having regard to my conclusion that there was evidence on the basis of which a verdict incorporating an element of neglect should have been left to the jury, the desirable course in this case in the interests of justice is to quash the verdict of the jury and to order a new inquest with a different jury.

LORD JUSTICE KEENE :

18. The death of yet another inmate is a depressing reflection on our prison system and there is inevitably even greater bitterness and loss felt by relatives and friends when the deceased is, as here, a young man of 22 held in prison on remand. This was a young man already diagnosed as a paranoid schizophrenic, who killed himself in the Wandsworth Prison health-care centre while (as the inquest jury found) the balance of his mind was disturbed. The fact that he suffered from that mental illness was known to those who were responsible for him at Wandsworth Prison. Yet he was put into a single cell, he was not put under systematic observation at prescribed intervals, and he was allowed to have his long laces in his trainers. With those laces he managed to hang himself. It all paints a very sorry picture.

19. This court, however, is concerned with very specific issues relating to the inquest. First and foremost, the issue is whether H.M. Coroner for West London should have left to the jury a verdict which included some reference to "neglect" as well as to Mr Craig having killed himself. That in turn depends upon whether there was evidence capable of properly supporting a verdict which encompassed some such reference. That issue is to be determined in the context of the function of a coroner's inquest, which is a matter of law. I emphasise that, because the role of an inquest is not to establish civil liability for the death or to indicate criminal liability on the part of a named individual: see rule 42 of the Coroners Rules 1984. Its task is set out in section 11 of the Coroners Act 1988. In particular, the proceedings are directed to establishing certain facts, namely who the deceased was and

"how, when and where the deceased came by his death".

(Section 11(5)).

20. It is well established that the reference in that provision to "how" the deceased came by his death means "by what means" rather than "in what broad circumstances": Reg -v- Walthamstow Coroner, ex p. Rubenstein (unreported) 19.2.1982 and Reg -v- North Humberside Coroner, ex p. Jamieson [1995] Q.B. 1. It is concerned with those acts and omissions which are directly responsible, in a causative sense, for the death. As it was put in Jamieson by the then Master of the Rolls, Sir Thomas Bingham, when dealing with a case with some similarities to the present one:

"Neither neglect nor self-neglect should ever form part of any verdict unless a clear and direct causal connection is established between the conduct so described and the cause of death". (P.26A)

21. In applying that approach, it must be borne in mind that the neglect or self-neglect need not be the sole or predominant cause of the death for it to be reflected in a verdict. A verdict may properly find that such matters contributed to a cause of death, though only if they did so in a more direct way than would be sufficient for the purposes of civil liability: see ex parte Homberg [1994] 158 J.P. 357 at 371.

22. All parties to this case are agreed that the issue as to whether a verdict incorporating an element of neglect should have been left to the jury is to be approached in the way outlined in R -v- Galbraith [1981] 73 Cr. App. R. 124. The issue thus becomes whether there was evidence at the inquest which, if accepted by the jury, could have led a reasonable jury, properly directed, to return such a verdict. While the coroner has a degree of discretion as to what verdicts he should leave to the jury, he should leave those verdicts which realistically reflect the thrust of the evidence as a whole: R -v- Inner South London Coroner, ex p. Douglas - Williams [1999] 1 All ER 344. In the present case, if the evidence was such that a proper verdict incorporating neglect could have been returned, no party suggests that the coroner should have refused to leave such a verdict to the jury through the exercise of his discretion. Nor would the fact that the representative at the inquest appearing for the deceased's family raised neglect only half-heartedly remove from the coroner his duty to leave such a verdict, given the inquisitorial nature of the process.

23. The legal principles to be applied in approaching such an issue of neglect were authoritatively set out in Jamieson. I bear in mind in particular conclusions 9, 11 and 12 in the judgment of Sir Thomas Bingham, M.R., already set out by Penry-Davey J. in his judgment in the present case. It is right, as Mr Simblet submitted, that such passages are not to be treated as if they were statutory enactments. They are part of the process of judicial interpretation of the law, which is a developing process. Nonetheless they represent a valuable distillation of the case law on the subject.

24. It is, of course, important to construe and apply those principles in Jamieson correctly. In that case the court was dealing with a prisoner who presented a suicide risk because he was depressed, apparently as a result of being a life sentence prisoner with a minimum term of 30 years to serve and with little contact with his family. He had expressed the intention orally and in writing of killing himself. He was evidently in control of his actions when he killed himself. The jury's verdict did not include a finding that the balance of his mind had been disturbed. It was in those circumstances that the Court of Appeal categorised the actions of the doctors and the prison authorities as doing no more than giving him an opportunity to take his own life.

25. That is a very different situation from that which may arise when the deceased is a person suffering from paranoid schizophrenia, hearing voices and frightened (as form 2052 SH recorded) that he might harm himself. That may well create a situation where that individual is very dependent on the prison and medical authorities to care for him and to prevent him from harming himself. He is not someone who is at all times in control of himself. The evidence in this case did not apparently cover what the voices which Mr Craig had been hearing had been telling him to do, but his fear that he might harm himself and the reference in the form 2052 SH to him having been reassured by staff at the magistrates court that there were no sharp objects in his cell there with which he could harm himself paints a picture of someone who in his rational moments is aware that at other times he is a danger to himself. In a case of that kind, the failure of the prison and medical authorities to take the necessary steps to prevent him killing himself could be seen by a jury as having a direct causal link with his death, just as in the example given in Jamieson of a patient with a propensity to swallow razor blades. If a person suffering from a delusion that he was a bird, that delusion being known to the authorities, were to be allowed access unattended to an open high point in a building, from where he then jumped to his death, the failure on the part of the authorities to protect him from the unintended consequences of his own actions may amount to neglect with a direct and clear causal connection to his death.

26. In the present case this court is not in a position to find that Mr Craig killed himself while suffering from a delusion such as hearing voices. That is not our function. There was evidence that he was still hearing voices at 7pm on 31 January when seen by Dr Pothalingam. Apparently he was not deluded or hallucinating at 4pm the next day when seen by Dr Muthalali, although it was not possible for that evidence to be explored at the inquest because Dr Muthalali was at that time too ill to attend. But it would seem that Mr Craig's delusions could come and go during a relatively short period of time. It is enough that the evidence was such that it would have been open to the jury to infer that he was suffering from such mental problems at the time of death, particularly given their verdict that at the time the balance of his mind was disturbed. It is a case which potentially may come within the "obvious example" given by Simon Brown L.J. in R -v- H.M. Coroner for Western District of East Sussex, ex p. Homberg [1994] 158 J.P. 357 at 370, namely "to leave unsupervised a mentally disordered person who thereupon committed suicide". That example was cited without dissent or criticism by the Court of Appeal in Jamieson. It remains a helpful piece of guidance.

27. As to whether the failings on the part of those at HMP Wandsworth were sufficiently pronounced as to allow a verdict that the death was contributed to by neglect, what is striking is the substantial amount of knowledge those persons had about Mr Craig's condition. It was known to them that he had been diagnosed as a paranoid schizophrenic; that he had attempted to harm himself on at least one occasion in the past, had expressed suicidal thoughts and had tried to open his wrists at court on 31 January (see the probation officer's Prisoner Warning Notice); that a Self Harm At Risk Form (2052 SH) referred to his fear that he might harm himself; that those responsible for him at court on 31 January had judged it desirable to remove his shoelaces, put him in a cell with another inmate and place him on a 15 minute watch; and that when seen by Dr Pothalingam at Wandsworth at 7pm that same day he was still hearing voices. That doctor, according to his evidence, judged him to be a suicide risk, but did not think that anything was likely to happen "imminently", because Mr Craig seemed at that time to be in a happy mood and not depressed.

28. Possessed of all that information, the decision was made merely to send him to the health-care centre under general observation. As no direction was given to remove shoelaces or other ligatures from him, his trainer laces were returned to him. He was put in his cell on his own. No observations at specific intervals were required.

29. All this seems to have flowed from the views formed by the medical practitioners at the prison, but that in itself, while relevant, cannot rule out neglect. There have been a number of cases where there had been medical attention but where neglect remained a possible element in a verdict: R -v- H.M. Coroner for Swansea and Gower, ex p. Chief Constable of South Wales [2000] 164 J.P. 191; R -v- H.M. Coroner for Wiltshire, ex p. Clegg [1997] 161 J.P. 521. Omissions on the part of medical practitioners are capable of forming part of the total picture which amounts to neglect.

30. Of course, hindsight is a wonderful advantage not possessed by those involved at the time. It may be that a jury would conclude that there was no contribution from neglect to Mr Craig's death. But there was evidence on which they could properly conclude that such a verdict was justified. In those circumstances the coroner was wrong not to leave such a verdict to the jury.

31. I agree that, in the light of that conclusion, it is unnecessary to deal with the argument raised about insufficiency of inquiry. I also agree that, for the reasons given by Penry-Davey J., this is a case where the verdict should be quashed and a new inquest ordered. That would have the additional advantage that it may enable Dr Muthalali to be called as a witness. His evidence as the last medical practitioner to see Mr Craig alive may have a greater importance than has hitherto been recognised.