Inquest Team E-Bulletin - October 2016

Peter Thornton QC took the opportunity in one of his last cases as Chief Coroner to urge coroners to avoid archaic language and speak in a way which juries can readily follow.

The case of R. v. Hamilton-Jackson v. HM Assistant Coroner for Mid Kent and Medway [2016] EWHC 1796 (Admin) concerned a man who had a history of mental health problems and self-harm. The inquest into his death investigated whether he should have been managed under the prison ACCT policy in the days leading up to his death, after he had superficially cut his wrist two days before.

Lord Justice Beatson and Judge Thornton ruled that the summing up was inadequate, rendering the jury’s conclusion unsafe and incompatible with art.2 of the European Convention on Human Rights. The judgment is of interest for a number of reasons:

  1. The court held that ‘the meaning of a policy is not a matter of fact to be determined by a jury’, indicating that the coroner should have determined the meaning of the ACCT policy and directed the jury accordingly. It was for the coroner, not the jury, to determine whether there was an inconsistency between national and local policies. The coroner ‘should have done more to help the jury …with an objective view of the meaning of the policies’.

  2. The court explored the fine line between ‘a narrative expression of a finding and a comment on a matter relevant to death, and an expression of opinion prohibited by section 5(3) Coroners and Justice Act 2009 (the prohibition on expression of opinion other than on statutory questions). The court considered the jury’s words in this case, which were comment on the difference between the national and local policies, to be ‘a comment on the matters concerning the national and local policies, a reflection on the difference in the wording of the two policy documents about the same issue because the local policy had not been update. All that is stated is that the amendments to national policy need to be reflected in the local policy’. The court did set aside the jury’s comments, but on the basis that the jury had been misdirected generally as to their approach to the policies, rather than because the comment was outside the jury’s remit.

  3. Although the court quashed part of the jury’s conclusion, the court found that there was no purpose to be sought by ordering a fresh inquest, and did not do so.

Hovering in the background to all of these legal issues was the verbiage used by the coroner in summing up, which included a question beginning: ‘was there a failure of system, by polarizing the dichotomy between…’. The Chief Coroner observed that coroners, however well intentioned, should do their best in directing a jury to avoid using language which is not in everyday use, and which might not be clearly understood. That admonishment, coupled with a call for greater legal aid provision, is a fitting parting shot for a Chief Coroner who has aimed to make proceedings accessible to all.

Kate Brunner QC

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