QUEEN'S BENCH DIVISION
B e f o r e :
|THE QUEEN ON THE APPLICATION OF P||Claimant|
|HER MAJESTY'S CORONER FOR THE DISTRICT OF AVON||Defendant|
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Mr Hugh Mercer QC (instructed by the Treasury Solicitor, London WC2B 4TS) appeared on behalf of the Defendant
Crown Copyright ©
MR JUSTICE BEATSON:
The facts and the submissions
"15.10 hrs at Eastwood Park Prison, Glos. cell E-114."
"Where an Inquest is held into a death in custody, in order to meet the Article 2 obligations, the Coroner must secure the jury's conclusions on how and by what means the deceased came by his death. Those questions cannot be answered merely by returning a verdict addressing the immediate physical cause of the death. Details of matters relevant to the death should be elicited from the jury." (emphasis added)
"Only two short form verdicts should be left open to the jury as an alternative to a narrative and they are suicide or accident and misadventure."
The Prison Ombudsman's Report
"Neither the coroner nor the jury shall express an opinion on any other matters."
"No verdict shall be framed in such a way as to appear to determine any question of criminal liability on the part of a named person or civil liability."
"If you do not consider that any of the above verdicts express your factual conclusions then you may return a narrative verdict, which is a short statement summarising your factual conclusions as to the circumstances in which [the deceased] came by her death. In this particular case, you can interpret the term how to include by what means, and by what means and in what circumstances. To return a narrative verdict, the act or omission must have contributed to the death in a more than minimal or trivial way. As with the other verdicts, the same rules apply, and the phrases you must not use are things like neglect or carelessness, as an example really."
"Where, in such a case, an inquest is the instrument by which the state seeks to discharge its investigative obligation, it seems that an explicit statement, however brief, of the jury's conclusion on the central issue is required."
"The investigation must also be effective in the sense that it is capable of leading to a determination of [in that case] whether the force used in such cases was or was not justified in the circumstances ..."
"This is not an obligation of result, but of means."
"The jury could thus indicate, by returning an open verdict, their inability to decide or, by choosing one or other of the remaining verdicts, express their judgment on the central, and very important, issue."
"was probably accelerated by a short time by the effect on her pneumonia of injuries sustained when she fell through an unattended open window [at her residential home]."