Law Report: Appeal over coroner's verdict on cell death is dismissed: Regina v North Humberside and Scunthorpe Coroner, Ex parte Jamieson

A verdict at an inquest that the deceased's cause of death was suicide contributed to by neglect or lack of care is justified only where gross neglect was directly connected with the deceased's suicide, and not where the deceased was afforded, through carelessness, an opportunity to take his own life.

The Court of Appeal dismissed an appeal by the applicant, the brother of the deceased, from the Queen's Bench Divisional Court's dismissal of his application for judicial review of an inquest verdict.

The deceased, a category A prisoner sentenced to life imprisonment in 1981, was known to the prison authorities to be suicide risk and spent some time in the prison hospital. In January 1991 he was re- admitted to hospital and put in a single cell. He was found dead in the cell. At the inquest, the coroner directed the jury not to return a verdict in which the words 'lack of care' formed a part. The jury found that the deceased had killed himself by hanging.

The applicant applied for judicial review on the ground that, since the deceased was not subject to special supervision in the hospital, the jury should not have been precluded from considering lack of care.

Ian MacDonald QC and Tim Owen (Ison Harrison, Leeds) for the applicant; Ian Burnett (Humberside County Council) for the coroner; Stephen Richards (Treasury Solicitor) as amicus curiae.

SIR THOMAS BINGHAM MR, giving the court's judgment, said that it was not the function of a coroner or his jury to determine any question of criminal or civil liability, or attribute blame. The coroner and jury might explore facts bearing on criminal and civil liability. But the verdict might not appear to determine any question of criminal liability on the part of a named person nor any question of civil liability.

There could be no objection to a verdict which incorporated a brief, neutral, factual statement, expressing no judgment or opinion.

Lack of care in the context of an inquest had been correctly described as the obverse of self-neglect. It was hoped that in future the expression 'lack of care' might be deleted from the lexicon of inquests and replaced by 'neglect'.

Neglect in this context meant a gross failure to provide adequate nourishment or liquid, or basic medical attention or shelter or warmth for someone in a dependent position, because of youth, age, illness or incarceration, who could not provide it for himself. Failure to provide medical attention for a dependent person whose physical condition was such as to show that he obviously needed it might amount to neglect, as it might if it was the dependent person's mental condition which obviously called for medical attention. In both cases the crucial consideration would be what the dependent person's condition, whether physical or mental, appeared to be.

Neglect could rarely, if ever, be an appropriate verdict on its own. A verdict that, for instance, the deceased died from natural causes, or industrial disease or drug abuse, to which neglect contributed seemed more apt than a verdict that he died from natural causes etc aggravated by neglect, since aggravated meant 'made worse', and the neglect probably did not make the fatal condition worse but sacrified the opportunity to halt or cure it.

Where the deceased took his own life, that must be the verdict. On such facts there was no room for a verdict of neglect. It was also inappropriate to describe the cause of death as aggravated by neglect. On certain facts it could possibly be correct to hold that neglect contributed to that cause of death, but that 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 was used in common speech or in the law of negligence) to afford the deceased that opportunity.

Such a finding would only be appropriate 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.

Neither neglect nor self-neglect should ever form any part of any verdict unless a clear and direct causal connection was established between the conduct so described and the cause of death. It was for the coroner alone to make reports with a view of preventing the recurrence of a fatality.

In the present case, there was no doubt that the deceased took his own life. That was the only possible verdict. The jury could not properly have found that neglect contributed to that cause of death. At its very highest, the applicant's case suggested that the doctors and prison authorities gave the deceased an opportunity to take his own life. Even if accepted, that would not support a verdict that neglect contributed to the suicide of the deceased.