QUEEN'S BENCH DIVISION
Strand, London, WC2A 2LL
B e f o r e :
| THE QUEEN ON THE APPLICATION OF SUTOVIC
|- and -
|HM CORONER NORTHERN DISTRICT OF GREATER LONDON
- and -
HM CORONER FOR NORTH LONDON
Smith Bernal Wordwave Limited, 190 Fleet Street
London EC4A 2AG
Tel No: 020 7404 1400, Fax No: 020 7831 8838
Official Shorthand Writers to the Court)
MR J. BEER (instructed by WITHERS LLP) for the Defendant
Crown Copyright ©
Lord Justice Moses handed down the following judgment of the court:
Under the heading:-
"Time, place and circumstances at or in which injury was sustained",
the coroner recorded:-
"In the early hours of 27 January 2004 the deceased was seen, lifeless at his mother's flat in Belgrade. There was no evidence as to the exact circumstances surrounding the death. He had previously been a drug abuser but his mother said that recent drug screens were negative."
Events leading to the inquest
"The death was most probably caused by an overdose of narcotics."
The report continues by recording that the death was established at 2.56am by a physician on duty, Dr Zivanovic, pursuant to the order of an investigation judge. The report says that the entrance door of the flat was locked and sealed and that the key of the flat was placed with the Secretariat of General Administration. The report continues:-
"On the spot was interviewed the deceased's friend, Sergej Nesic… has known the deceased who used to visit the place as a guest. He further declared that starting from two weeks ago he has lived at the deceased's place and that he had to agree with the deceased to continue living there as a sub-tenant. According to Nesic, the deceased was a treated drug addict; however, three days ago when he came from work he found the deceased in the flat who according to his physical aspect and behaviour gave an impression of a man under the effect of drugs and, therefore, he, Nesic, concluded that the deceased started to be on drugs again and added that on 26 January, around 11.20pm Sutovic came to the flat where already were Sergej Nesic and a friend of both of them. Zoki Cupac, a citizen of Australia…on which occasion, after dinner, Sutovic went to his room leaving the two of them alone, and when on 27 January about 2.30am Nesic entered his room you found him dead and with the tools for drug administering beside him, which was confirmed by Cupac when he was interviewed.
In the interview held with the patrol on duty of this Internal Affairs Unit, these two persons confirmed that when coming to the spot they saw a syringe and a needle stuck in the deceased's left arm, which fell out while paramedics were rendering aid to the deceased.
A crime-laboratory technician, Emus Ranko, inspected the body on the spot from which he took one used syringe with a needle, three more needles, one metallic spoon, two foils from cigarette boxes with the traces of brown powder on them, and two halves of tablets of the same colour, which will all be forwarded to OKT."
"A violent death, caused by intake of drugs."
The reference to violent death, it was agreed, signified no more than that which follows, namely, intake of drugs.
"His nose does not resemble…he does not look himself."
It is important to note that the claimant responded:-
"But when I saw him after two days, when he arrived here, his face was totally normal…nothing swollen, nothing, nothing."
The claimant repeated that and the housekeeper responded that she was told by someone who had prepared the body that there were no marks on the face.
"No apparent old or recent injection marks were seen…No injuries were seen."
"Death was associated with a potentially fatal blood level of Morphine. Six other drugs were present at therapeutic levels. There was no evidence of hypoglycaemia."
This pathologist then recorded the cause of death as "morphine poisoning".
"On the wall, on the wall as if something burst on to it…It looks as if he was hit and that, that burst…"
"My son has never taken morphine, save as a prescribed drug whilst he was in hospital in Israel after a horrendous traffic accident where he was given a 5% chance of survival in 2000."
The letter continued by asserting that her son had undertaken drug tests for the past two years, implying that he was not abusing drugs. She stated that she suspected that her son had been murdered. She continued in later letters in a similar vain.
"I have had my own pathology and toxicology performed which indicates that morphine poisoning is the cause of death, and you will be aware of this.
The other matters to which you refer may not be central to my enquiry but I thank you for drawing them to my attention.
I have no powers in relation to investigations abroad, as you will know but have to rely on the evidence presented to me. I am sorry not to be more helpful…"
"the full and detailed file relating to your son's death and for going over them with my officers. Clearly they raised new questions which will have to be explored. This may take some time, and may require further police involvement."
"I have studied the bundle of papers and translations for which I am grateful and thank you for pursuing your own enquiries so assiduously. There is no need to provide me with any more information at this stage. I have also had the opportunity for discussing matters face to face with Professor Jack Crane, whom you have involved independently in your enquiries, as an expert. I will not need to call him as a witness."
"The statement of Mitrovic, dated 27 January 2004 (the defendant's bundle A1, pages 134-135);
the Belgrade autopsy, dated 28 January 2004 (A1, pages 136-141);
English language transcripted telephone interview with housekeeper (A1, pages 142-161);
English language statement of Nesic taken by the private detectives engaged by the claimant (A1, pages 162-163);
report of the autopsy and subsequent toxicology reports with letter from Jenny Button (A1, pages 163a-169).
In addition there were nine original colour photographs of the claimant's son, one taken in life and others which appear to be taken at or after the time of death (A2, pages 417-419)."
The coroner accepts that apart from the UK autopsy, all those documents were supplied to him by the claimant:-
"As part of three folders of material which she had collected, I selected the items which I considered would be most useful for my enquiry."
The Duty of the Coroner
"The Coroner shall, at the first sitting of the inquest, examine on oath concerning the death all persons who tender evidence as to the facts of the death and all persons having knowledge of those facts whom he considers it expedient to examine."
Section 11(5)(b) provides that an inquisition -
"…shall set out, so far as such particulars have been proved -
(i) who the deceased was; and
(ii) how, when and where the deceased came by his death."
"(1) The proceedings and evidence at an inquest shall be directed solely to ascertaining the following matters, namely -
(a) who the deceased was;
(b) how, when and where the deceased came by his death;
(c) the particulars for the time being required by the Registration Acts to be registered concerning the death.
(2) Neither the Coroner nor the jury shall express any opinion on any other matters."
Rule 37 provides:-
"(1) Subject to the provisions of paragraphs (2) to (4), the Coroner may admit at any inquest documentary evidence relevant to the purposes of the inquest from any living person which in his opinion is unlikely to be disputed, unless a person [such as the claimant] objects to the documentary evidence being admitted.
(2) Documentary evidence so objected to maybe admitted if in the opinion of the Coroner the maker of the document is unable to give evidence within a reasonable period;
(3) Subject to paragraph (4), before admitting any such documentary evidence the Coroner shall at the beginning of the inquest announce publicly -
(a) that the documentary evidence may be admitted, and
(b) (i) the full name of the maker of the document to be admitted in evidence, and
(ii) a brief account of such document, and
(c) that [a person including the claimant] may object to the admission of any such documentary evidence…."
"It is the duty of the Coroner…to ensure that the relevant facts are fully, fairly and fearlessly investigated. He is bound to recognise the acute public concern rightly aroused where deaths occur in custody. He must ensure that the relevant facts are exposed to public scrutiny, particularly if there is evidence of foul play, abuse or inhumanity. He fails in his duty if his investigation is superficial, slipshod or perfunctory. But the responsibility is his. He must set the bounds of the inquiry. He must rule on the procedure to be followed. His decisions, like those of any other judicial officer, must be respected unless and until they are varied or overruled."
The judicial review claim
Rule 37(3) Public announcement of the right to object
"By this stage, as well as having sought to commission an independent report of Professor Crane, the Claimant had commissioned a forensic report from a Mr Fordy, a former Detective Superintendent, further forensic analysis of the clothing and blood stains by a Terence Merston, forensic photographic analysis by a Mr Canning, a forensic photographer, as well as forensic blood pattern expert evidence, and the evidence of a forensic scene examiner (Allan Bayle). The Defendant was, the Claimant says, aware of all of this. The Claimant also says that she informed the Defendant's officers that she would if need be secure the attendance of witnesses from Serbia."
"Was telling me as a matter of courtesy that on the evidence which he had seen he had not reached any concluded view. Given this, I concluded that Professor Crane could offer no evidence that could assist my inquiry." (paragraph 57).
Application under Section 13 Coroners Act 1988
"on suspicion and assumptions resulting from observations and analyses of photographs taken in the apartment of the deceased at different times by different persons, and other records available to them."
"1) The punctures in the arm of the deceased were not photographed close up;
2) The syringe with the needle attached taken from under the bed was not photographed;
3) The belt lying on the floor by the bed was not photographed;
4) Several spotty but stains suggestive of blood on the left lateral wall were neither noticed nor photographed nor sampled;
5) The report of the junior sergeant recording that a needle was found stuck into the left arm of the deceased was incorrect;
6) The crime technician, Rmus, failed to record that the deceased had a white athletic shirt on; and
7) Items were not taken for analysis from either the deceased's room or other rooms such as the burnt metal spoon, bottles of unidentified white powder and cigarette butts."
The report concludes that there were shortcomings in the operation of members of the police department.
"There is unequivocal evidence of flattening of the nasal bridge and some deviation of the nose itself."
He also refers to evidence of soft tissue swelling and reddening of the left eyelid and swelling of the upper lip area. He states that this is strong evidence of a significant facial trauma involving the nasal bridge and nasal skeleton suggesting some direct violence very shortly before he met his death.
"The natural post-mortem process of hypostasis (otherwise called lividity)."
He says that is common. The apparent soiling is due to leakage of fluids from the mouth and nose either at the time of death or afterwards. He says this is very common, particularly when a deceased is lying face down. He says that it is not uncommon for a nose to appear distorted when someone has been lying face down after death. If there had been a blow to the nose or the nose had been broken he would have expected a significant quantity of bright red fresh blood at the scene.
"In reporting on cases of drug misuse deaths, I have often encountered many features that do not add up; witness accounts differ and pieces of evidence are often inconsistent. However, in the present case, I can see no reason to suggest that Petar Sutovic did not die of opioid toxicity or that foul play played a part in his death."
"There was further evidence of force with the ripped stitching of the Champion vest and the blue sleeveless jacket."
The Champion vest was worn at the time of death but in the body of the report he accepts the damage may have been done during the removal of clothing from the body. The blue sleeveless jacket is not illustrated and appears merely to have been an item found subsequently in the flat. The presence of blood on that jacket could not possibly support any conclusion as to violence at the time of death. The expert makes no reference to that obvious observation.
"One explanation could be that Petar Sutovic was lying face upwards in a pool of blood, clothed in the diesel jacket over the Kappa cardigan which in turn was over the Fred Perry shirt and vest. As the top layers of clothing were removed Petar was laid back in the pool of blood."
There is, however, no evidence whatever that the deceased was wearing any of those items at the time of death. Moreover, it is absurd to suggest that he would have been clothed by his relative and the housekeeper with items of clothing drenched in his blood. The claimant has already revealed that a process of selection took place. Mr Wade does not even suggest that that might be an explanation. This is a report, interpretation of which is inevitably hampered by the absence of any material to show what was laid before him by way of instructions, over which there are a number of significant question marks. In these circumstances we do not consider it to be a basis on which to order another inquest.
"Could it be possible that Petar sustained a further serious assault following the police scene photographs, which could explain the heavily blood stained clothing, which was subsequently photographed?"
This suggestion is clearly false considering that there is no evidence of heavily blood stained clothing at the scene. This expert's detailed comments on the photography does not, in my view, assist. Nor does he seem to have been told that the jeans in which Petar's body was clothed after death were not the same jeans as those in which he was found at the time of death.
"made to look like a drugs overdose."
reveals that he was not told that the body had been moved or what happened when paramedics, the doctor and subsequently the police arrived. He comments that a video shows that items had been transplanted. But that is of no relevance once it is appreciated that the private investigators, retained by the claimant, tampered with the scene. Clearly he had never been shown the Ministry of Interior report, dated 25 April 2005. His report is of no value.
"The results in the relevant case could, for example, compatible with Mr Sutovic being intoxicated at the time of death with death actually being caused by smothering. Other explanations are also possible, for example that he was a regular user of high dose morphine for therapeutic purposes and his death is due to an unrelated case (sic)."
"In all probability unlawfully killed."
He also makes comments as to what the deceased was wearing at the time of his death which have been falsified by what has been learnt during the course of the Ministry of Interior investigation subsequently. In particular, he records Mr Mitrovic's evidence that he thought the deceased was naked from the waist up. That does not now appear correct.
"that morphine may have been the sole cause of death cannot be denied but neither can the suggestion that it was merely an incidental finding in a death caused by some other factor."
He concludes that because there is no evidence to prefer any various possible causes of death, including arrhythmia and the presence of a raised blood glucose associated with diabetes, the cause of death would be best expressed as "unascertained". He says he has seen no evidence to suggest that trauma played any part in the death.
Conclusion as to expert evidence