Article 2 Inquests

The State has obligations to protect life, pursuant to the European Convention on Human Rights (ECHR), to which the UK is a signatory.

Article 2 of the Convention states:

See the ECHR Summary Guide to Article 2 for a useful introduction. We have digested a number of cases where Article 2 has been applied: see our Digest of Inquest Case Law for more details.

State Obligations

Pursuant to Article 2, the State is required to properly investigate and take action to prevent deaths (“the positive obligation”), in certain prescribed circumstances. To demonstrate compliance with Article 2, an inquest may need to scrutinise the circumstances surrounding a death, to an enhanced degree, in comparison to other inquests where the obligation is not triggered. (This is sometimes known as a Middleton inquest, named after a seminal case, as opposed to a narrower Jamieson inquest, which is another seminal case, that requires a narrower scope on inquiry during at inquest hearing.) The distinction may be less strict in some inquests, as the scope of an inquest may end up covering the same issues through calling the same witnesses that would have been called to give evidence at an Article 2 inquest: R (Kent County Council) v HM Coroner for the County of Kent [2012] EWHC 2768 (Admin).

In the case of Fernandes de Oliveira v Portugal (2019) 69 EHRR 8 [at para 103], it was held that Article 2 contains two “distinct albeit related obligations”: firstly a systemic duty to protect life and, secondly but of equally important status, an operational duty to protect life:

“103.  The Court notes at the outset that the present case concerns an alleged act of medical negligence within the context of a suicide during a period of voluntary hospitalisation in a State psychiatric institution. Accordingly, two distinct albeit related positive obligations under Article 2, already developed in the jurisprudence of the Court, may be engaged. First, there exists a positive obligation on the State to put in place a regulatory framework compelling hospitals to adopt appropriate measures for the protection of patients’ lives (see paragraphs 104-7 below). Second, there is a positive obligation to take preventive operational measures to protect an individual from another individual or, in particular circumstances, from himself…”

Article 2 inquests may need to focus on both duties, or just one, depending on the circumstances leading to the individual’s death. An operational duty requires those with responsibility to take reasonable steps to reduce the risk of harm that could lead to death. Any failure to do this can fall within the scope of an Article 2 inquest.

Where it is credible or arguable (more than fanciful) that there has been a failure to meet the obligations of Article 2, an Article 2 style inquest should usually be held. This is not as clear-cut as it sounds, but is a good rule of thumb. Each case turns on its own facts, of course, and significant legal argument may be necessary to persuade a coroner to hold an Article 2 style inquest.

The cases of (R (Gentle) v Prime Minister (2018) 1 AC 1356 (at para 6); and R (Skelton) v Senior Coroner for West Sussex (2020) EWHC 2813 (Admin) (at para 63) set out the threshold, which is considered to be a low one. Some coroners may keep an poen mind and see where the evidence takes the case, and expand the inquest on the hoof. In some cases, the inquest will be treated as an Article 2 style inquest.

In Gentle above, it was held (para 8): “the procedural obligation under article 2 is parasitic upon the existence of the substantive right, and cannot exist independently. Thus to make good their procedural right to the enquiry they seek the appellants must show, as they accept, at least an arguable case that the substantive right arises on the facts of these cases. Unless they can do that, their claim must fail.” 

And in Skelton, above, it was held: “The threshold for the procedural obligation to arise is that there has been an arguable breach of an article 2 substantive obligation. This threshold is a low one because to impose a more onerous burden would run the risk of the Coroner determining, in advance of the full evidential picture, what the outcome of any inquest might be. ‘Arguable’ in this context means anything more than fanciful”.

Where a death occurs in prison or police custody, an Article 2 inquest will be held. An Article 2 inquest will also usually be held where a patient is detained under the Mental Health Act 1983. Where there is a hospital death in other circumstances, an Article 2 style inquest might also be required. The circumstances and location of some other deaths might also necessitate an Article 2 inquest.

In R (Parkinson) v HM Senior Coroner for Kent [2018] EWHC 1501 (Admin) it was held that in a hospital and healthcare settings, the operational duty may have less of a role. The applicability of Article 2 obligations in healthcare or quasi-healthcare settings is to be considered on appeal (as of March 2023) in the Supreme Court, in the case of R (Maguire) v HM Coroner for Blackpool and Fylde. See the Court of Appeal judgment which is the subject of the appeal: R (Maguire) v HM Senior Coroner for Blackpool & Fylde & Ors [2020] EWCA Civ 738. In that case  XXX

In the case of Traskunova v Russia (application No. 21648/11 on 30/11/22 [at paras 75 to 80]: A substandard or non-existent legal, administrative, and regulatory framework could potentially amount to a breach of Article 2.

See our Digest of Cases for further Article 2 Case Law. 

See our article on Obtaining Legal Aid in Article 2 Cases.

Call Inquest Representation Service on 033 00 77 00 97 for more information about how we can advise on Article 2 inquests. All calls are treated in confidence and are without obligation.