Davies, R (on the application of) v HM Deputy Coroner for Birmingham [2003] EWCA (Civ) 1739 (02 December 2003)

Davies, R (on the application of) v HM Deputy Coroner for Birmingham [2003] EWCA (Civ) 1739 (02 December 2003)

The coroner's directions were legally deficient for failing to allow the jury to consider whether systemic neglect contributed to the death, and for not making clear that a clinical judgment could still amount to neglect. Article 2 ECHR required a public finding on systemic neglect, which was not achieved. The...

Source-derived case information.

Citation
[2003] EWCA (Civ) 1739
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 / Appeal From Administrative Court to Court of Appeal (civil Division)
Outcome
Appeal allowed; inquisition quashed; new inquest ordered.
Legal Topics
Inquest Verdicts, Neglect in Custody, Article 2 ECHR Procedural Obligations, Systemic Neglect, Judicial Review of Coroners' Decisions
Public Law Human Rights Law Coronial Law Inquest Verdicts Neglect in Custody Article 2 ECHR Procedural Obligations Systemic Neglect Judicial Review of Coroners' Decisions

Source-derived case record

Summary, issues, holding and outcome

More case intelligence is available

Unlock the full research layer for this judgment.

Full judgment text Downloadable case file Legal principles 4 Authorities cited 13 Party arguments 2 Amounts and remedies 3
Sign in to unlock

Parties

Christine Davies

Claimant/appellant

HM Deputy Coroner for Birmingham

Defendant/respondent

Procedural Posture

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

Legal Issues

  1. 1 Whether the coroner's directions to the jury on neglect were legally adequate
  2. 2 Whether the jury should have been permitted to consider systemic neglect as a contributory cause of death
  3. 3 Whether exclusion of certain expert evidence was lawful

Ratio Decidendi

The coroner's directions were legally deficient for failing to allow the jury to consider whether systemic neglect contributed to the death, and for not making clear that a clinical judgment could still amount to neglect. Article 2 ECHR required a public finding on systemic neglect, which was not achieved. The inquisition must be quashed and a new inquest held.

Court Disposition

Appeal allowed; inquisition quashed; new inquest ordered.

Orders

  • The previous inquisition is quashed.
  • A new inquest must be held to determine whether systemic neglect contributed to the death.