Davies, R (on the application of) v HM Deputy Coroner for Birmingham

Davies, R (on the application of) v HM Deputy Coroner for Birmingham

The inquest failed to fulfil the procedural obligations under Article 2 ECHR because the coroner did not properly direct the jury on the possibility of a verdict of neglect, including systemic neglect, and excluded relevant evidence. As the inquest was the only realistic means of public investigation, the verdict must be quashed and a new inquest held to consider systemic neglect.

Parties
Claimant/appellant: Christine Davies; Defendant/respondent: HM Deputy Coroner for Birmingham
Jurisdiction
England and Wales
Judgment Date
02 December 2003
Procedural Posture
Judicial Review Appeal / Court of Appeal (civil Division) Appeal From Administrative Court
Outcome
Appeal allowed; inquisition quashed; new inquest ordered
Legal Topics
Inquests, Neglect, Systemic Neglect, Article 2 ECHR, Death in Custody, Judicial Review
Public Law Human Rights Law Prison Law Inquests Neglect Systemic Neglect Article 2 ECHR Death in Custody +1 more

Case Brief

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Parties

Christine Davies

Claimant/appellant

HM Deputy Coroner for Birmingham

Defendant/respondent

Procedural Posture

Judicial Review Appeal / Court of Appeal (civil Division) Appeal From Administrative Court

Legal Issues

  1. 1 Whether the coroner's directions to the jury were deficient regarding the possibility of a verdict of neglect, including systemic neglect, in the death of Darren Davies in custody.
  2. 2 Whether the exclusion of certain evidence and failure to leave systemic neglect to the jury rendered the inquest inadequate for Article 2 ECHR purposes.

Ratio Decidendi

The inquest failed to fulfil the procedural obligations under Article 2 ECHR because the coroner did not properly direct the jury on the possibility of a verdict of neglect, including systemic neglect, and excluded relevant evidence. As the inquest was the only realistic means of public investigation, the verdict must be quashed and a new inquest held to consider systemic neglect.

Court Disposition

Appeal allowed; inquisition quashed; new inquest ordered

Orders

  • The inquisition is quashed.
  • Unless an alternative inquiry is set up, the coroner must hold a new inquest focused on whether systemic neglect contributed to the death.