Calvert, R (on the application of) v HM Coroner for Inner North London & Anor, Court of Appeal - Administrative Court, April 03, 2009,  EWHC 661_2 (Admin)
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Neutral Citation Number:  EWHC 661 (Admin)IN THE HIGH COURT OF JUSTICEQUEEN'S BENCH DIVISIONADMINISTRATIVE COURTRoyal Courts of JusticeStrand, London, WC2A 2LL Date: 03/04/2009 Before : SIR THAYNE FORBESSitting as a Judge of the High Court- - - - - - - - - - - - - - - - - - - - Case No: CO/5198/2007Between : - - - - - - - - - - - - - - - - - - - - - (Transcript of the Handed Down Judgment ofWordWave International LimitedA Merrill Communications Company190 Fleet Street, London EC4A 2AGTel No: 020 7404 1400, Fax No: 020 7831 8838Official Shorthand Writers to the Court)- - - - - - - - - - - - - - - - - - - - -Paul Bowen (instructed by Bhatt Murphy Solicitors) for the Claimant Keith Lewis Hugh Southey and Adam Straw (instructed by Coninghams Solicitors) for the Claimant Gwendoline Calvert Hugh Southey and Adam Straw (instructed by Christian Khan Solicitors) for the Claimant Susan Woods Jonathan Hough (instructed by Legal & Democratic Services, Shropshire County Council) for HM Coroner for the Mid and North Division of Shropshire Jason Coppel (instructed by Legal Services, Oxfordshire County Council) for HM Coroner for Oxfordshire Jenni Richards and Colin Thomann (instructed by the Treasury Solicitor) for The Secretary of State for Justice Hearing dates: 25th, 26th, 27th November and (by further written submissions) 5th December 2008 - - - - - - - - - - - - - - - - - - - - -JudgmentSir Thayne Forbes : Introduction.1. These three linked applications for judicial review and/or claims under the Human Rights Act 1998 (to which applications/claims, where appropriate, I will hereafter refer respectively as JR1, JR2 and JR3) are all concerned with the rulings and/or directions made and/or given by the various coroners who conducted inquests into the deaths in custody of Karl Christopher Roy Lewis (JR1), Paul Darren Calvert (JR2) and Stephen Woods (JR3). The Defendant in each case is the Coroner who held the inquest in question and, in all three cases, the Secretary of State for Justice (``the Secretary of State''), who is responsible (inter alia) for the Prison Service, is joined as an Interested Party. On 10th April 2008, His Honour Judge Mackie QC ordered that the three applications/claims were to be heard together, with JR1 as the lead claim. 2. A Brief Overview of JR1. In JR1, the Claimant is Keith Lewis, the father of the deceased, Karl Christopher Roy Lewis (``Karl''). Subject to one aspect of the claim (as to which, see below), on 29th June 2007 McCombe J granted permission to apply for appropriate relief by way of judicial review of the Coroner's ruling and directions to the Jury at the inquest held, in October 2006, into Karl's death.3. Shortly stated, the general circumstances relating to JR1 are these. In the early hours of the morning of 22nd January 2005, Karl was found hanging in his cell at HM YOI Stoke Heath (``YOI Stoke Heath''). He was then aged 18, having been born on 29th August 1986. A first inquest into Karl's death commenced on 30th January 2006, but the jury was discharged on 5th February when it was discovered that several jurors had connections with parties involved in the proceedings. A second inquest (``the inquest''), conducted by Mr John Penhale Ellery (``the Coroner''), took place over a period of eight days, between 5th and 16th October 2006. 4. The subject of the Claimant's challenge/claim in JR1 is the Coroner's ruling (``the ruling''), made with written reasons on 18th October 2006 (confirming an earlier oral ruling given on 12th October 2006), that the Jury could not consider questions relating to the actions of the Prison Service after Karl had been found hanging in his cell, on the grounds that the Jury's role was limited to considering ``factual questions directly relating to the cause or contribution to the cause'' of death. The Coroner therefore ruled that, because there was no evidence that Karl was alive when he was found, any acts or omissions by the Prison Service thereafter could not, on the balance of probabilities, be shown to have caused or contributed to his death. Accordingly, the Jury had no jurisdiction to address those questions in their verdict. 5. In due course, the Jury were invited to give an extended verdict by way of answers to a series of questions. In the inquisition, the Jury recorded their conclusion that Karl had hanged himself, intending to take his own life. They also went on to make a series of findings of failures by the Prison Service, Telford and Wrekin Borough Council and YOI Stoke Heath that had caused or contributed to Karl's death.6. The particular matters with which the Claimant is concerned in JR1 relates to the actions of the night patrol officer at Stoke Heath, OSG (Officer Support Grade) Knowles, the officer who discovered Karl hanging in his cell from a ligature at 1.19 am on the morning in question. At the inquest, OSG Knowles gave evidence to the effect that, rather than entering the cell immediately to give assistance to Karl, he radioed for back-up from other officers and then waited for those officers to arrive before entering the cell and rendering assistance to Karl.7. There was conflicting evidence before the Jury from OSG Knowles and the officers who attended to assist (POs Johnston, Doherty and Kershaw) as to the time it took between the alarm being raised and their attendance at the scene, although it was in the order of minutes. It also emerged during OSG Knowles' evidence that he had not received suicide prevention training or any other relevant training, nor had he (or any other officers) been issued with a so-called ``fish-knife'', a safe instrument for cutting a ligature, and there appeared to be conflicting guidance as to the appropriate steps to be taken when an officer is confronted with a detainee in a life-threatening situation. 8. As a result of the Coroner's ruling, the Jury were not permitted to make any findings relating to any of the matters summarised in paragraph 7 and, although the Coroner did make certain Rule 43 recommendations (as to which, see below), he made no recommendations relating to any of those matters. 9. On behalf of the Claimant, Mr Bowen submitted that, for reasons dealt with more fully later in this judgment, the Coroner's ruling was wrong in law and in breach of Article 2 of the European Convention on Human Rights (``the ECHR''). It is to be noted that the Claimant also sought to challenge the Coroner's failure to make a Rule 43 recommendation to the effect that ``All prison officers on night duty should have full training in relation to suicide and self-harm prevention and first aid and should be issued with equipment that enables them to cut the ligature of an inmate who is found hanging.'' However, the application for permission to pursue this aspect of the claim was refused by McCombe J on 29th June 2007 and has not been renewed.10. Furthermore, the Claimant's original claim for relief sought (inter alia) orders quashing the inquisition and verdict in question and requiring the Defendant to hold a new ``Article 2 compliant'' inquest. However, in the course of his submissions and in his detailed written skeleton argument (see paragraph 113), Mr Bowen made it clear that these particular orders were no longer sought by the Claimant, who would be satisfied with appropriate declaratory relief if his claim is successful.11. A Brief Overview of JR2. In JR2, the Claimant is Gwendoline Calvert, the mother of the deceased, Paul Darren Calvert (``Paul''). On 22nd November 2007, Kenneth Parker QC, sitting as a Deputy High Court Judge, granted permission to apply for appropriate relief by way of judicial review of the Coroner's directions to the Jury at the inquest held, in March 2007, into Paul's death and of the Coroner's decision not to leave the adjectival verdict of ``neglect'' to the Jury.12. Stated shortly, the general circumstances relating to JR2 are these. At 2.29 pm on the afternoon of 24th October 2004, Paul was found hanging by a belt tied round his neck and attached to a closed window at the end of his cell at HMP Pentonville. He was then aged 40, having been born on 1st April 1964. The inquest into Paul's death was held by Dr Andrew Scott Reid (``the Coroner'') at St Pancras Inner North London Coroner's Court from 26th to 29th March 2007.13. It is the Claimant's case that, at the inquest, there was evidence upon which a Jury, properly directed, could have made the following narrative findings, namely that:(i) there was a failure to ensure that the Prison Escort Report in Paul's case was received by those assessing Paul on his reception at HMP Pentonville, in particular by the officer conducting the suicide risk assessment within the First Reception Health Screen;(ii) the First Reception Health Screen suicide risk assessment was inadequate;(iii) there was insufficient staff at reception on the evening of 22nd October 2004 to conduct the reception process properly;(iv) officers failed to pay adequate attention to concerns expressed about Paul's suicide risk;(v) prison officers seriously failed to pay proper attention to the emergency alarm panels from 1.40 pm to 2.30 pm on 24th October 2004;(vi) officers wrongly expected inmates to answer Paul's emergency cell alarm, rather than responding themselves;(vii) the audible signal from the emergency alarm panels on E and A wings had been disabled for a substantial period;(viii) the prison failed to take proper steps to repair the audible signal on the emergency alarm panels in E and A wings;(ix) there was no appropriate system of checks and maintenance on the emergency alarm panels in E and A wings; and(x) officers did not have appropriate tools to cut the belt from Paul's neck, such as a ``fish-knife''.14. In his summing up, the Coroner decided to leave to the Jury short-form verdicts of suicide (or similar), misadventure and an open verdict. However, he decided not to leave the adjectival or ancillary verdict of neglect to the Jury, since he was not...
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