Judgments - Regina v. Her majesty's Coroner for the County of West Yorkshire (Appellant) ex parte Sacker (FC) (Respondent)

(back to preceding text)

    24.  Having read the inquisition, the appellant made the following statement before he closed the inquest:

    "Just before I formally conclude this inquest I intend now making an announcement pursuant to rule 43 of the Coroners Rules that it is my intention to write to the prison department and inform them as to my grave concerns regarding the locum medical officer at New Hall Prison on this occasion not having a working knowledge of the form 2052SH procedures. I regard the form 2025SH as a vital tool in identifying those prisoners who are vulnerable and at risk of self harm or suicide and I take an extremely dim view of the fact that somebody in such an important position as a medical officer albeit a locum on this occasion demonstrated such a scant understanding of what is such an important provision and therefore I shall write to the Head of the Prison Service pointing out my concerns pursuant to this rule."

    25.  No criticism is made, nor could any criticism properly be made, of the appellant's decision to draw the gap in Dr Spivack's knowledge of the F2025SH procedures to the attention of the Prison Service. It was clearly open to him to do this in view of the terms of rule 43, and it was a reasonable step for him to have taken in the light of Dr Spivack's evidence. But it would, I think, be a misconception to conclude from the fact that he chose to take this course that this was the only ground on which it could reasonably be said that Ms Creamer's death was due to a failure in the content or operation of the system that ought to have prevented her suicide.

    26.  It is plain that Ms Creamer, like so many other women in prisons, fell within the profile of those who most commonly die while they are in custody. She was a young woman, she was unconvicted and she was withdrawing from drugs. It is plain too that she was placed on her own in a cell without a television set where material was available for her to hang herself. The tragedy which occurred in her case is that these factors came together to create the dark, desperate sense of isolation and hopelessness that drives a person to contemplate, and then to commit, suicide. There are signs in the report commissioned by Mr Clifford that this tragedy might have been prevented if there had been better communication between members of staff with each other and between staff and prisoners. It may be too that it was a mistake to rely on the routine system of half-hourly inspections in her case as this left ample time for prisoners, aware of the system, to take measures while they were unobserved that could lead to self-harm and ultimately to suicide.

Conclusion

    27.  As Lord Bingham of Cornhill, giving the opinion of the Appellate Committee, has explained in R v H M Coroner for the Western District of Somerset, Ex p Middleton [2004] UKHL 10, paras 34-35, the scheme for the conduct of inquests which has been enacted by and under the authority of Parliament must be respected, save to the extent that a change of interpretation is required to honour the international obligations of the United Kingdom under the Convention. The word "how" in section 11(5)(b)(ii) of the 1988 Act and rule 36(1)(b) of the 1984 Rules is open to the interpretation that it means not simply "by what means" but rather "by what means and in what circumstances". The provisions of section 3 of the Human Rights Act 1998 indicate that it should now be given the broader meaning, with the result that a coroner will be able to exercise his discretion in the way Lord Bingham has indicated in paras 36 and 37 of the opinion in that case.

    28.  The coroner in this case did not have an opportunity of inviting the jury to consider the issues in the way which Lord Bingham has now identified. This deprived the inquest of its ability, when subjecting the events surrounding Ms Creamer's death to public scrutiny, to address the positive obligation that article 2 of the Convention places on the State to take effective operational measures to safeguard life: Osman v United Kingdom (1998) 29 EHRR 245, paras 115-116. The inquest was not able to identify the cause or causes of Ms Creamer's suicide, the steps (if any) that could have been taken and were not taken to prevent it and the precautions (if any) that ought to be taken to avoid or reduce the risk to other prisoners. The most convenient and appropriate way to make good this deficiency is, as the Court of Appeal did, to order a new inquest.

    29.  It should be noted that, although the inquest took place after 2 October 2000 when the relevant provisions of the Human Rights Act 1998 came into operation, the death occurred before that date. The respondent's contention in her claim for judicial review that this was a case of an ongoing breach of article 2 has not been challenged at any stage in these proceedings. But there has been no decision on the point, and nothing that has been said in this opinion should be taken as having had that effect.

    30.  The Committee is of the opinion that the appeal should be dismissed.

APPENDIX I

    ORDERS OF REFERENCE, ETC.

    WEDNESDAY 13 NOVEMBER 2002

    Appellate Committees—Two Appellate Committees were appointed pursuant to Standing Order.

    ____________________

    TUESDAY 20 MAY 2003

    Regina v. Her Majesty's Coroner for the County of West Yorkshire (Appellant) ex parte Sacker (Respondent)—The appeal of Her Majesty's Coroner for the County of West Yorkshire was presented and it was ordered to be that in accordance with Standing Order VI the statement and appendix thereto be lodged on or before 1 July next.

    ____________________

    MONDAY 2 JUNE 2003

    Regina v. Her Majesty's Coroner for the County of West Yorkshire (Appellant) ex parte Sacker (Respondent)—It was ordered that the appellant be allowed to prosecute the appeal without giving the usual security for costs as required by Standing Order.

    ____________________

    TUESDAY 1 JULY 2003

    Regina v. Her Majesty's Coroner for the County of West Yorkshire (Appellant) ex parte Sacker (Respondent)—The appeal was set down for hearing and referred to an Appellate Committee.

    ____________________

    WEDNESDAY 26 NOVEMBER 2003

    Appellate Committees—Two Appellate Committees were appointed pursuant to Standing Order.

    ____________________

APPENDIX II
MINUTES OF PROCEEDINGS
MONDAY 2 FEBRUARY 2004
Present:
L. Bingham of CornhillB. Hale of Richmond
L. Lord Hope of CraigheadL. Carswell
L. Walker of Gestinghorpe 
The Lord Bingham of Cornhill in the Chair.

    The Orders of Reference are read.

    The Committee deliberate.

    Counsel and Parties are called in.

      Mr I. Burnett QC and Mr J. Findlay appear for the appellant.

      Mr R. Gordon QC and Mr S. Cragg appear for the respondent.

    Adjourned until tomorrow.

TUESDAY 3 FEBRUARY 2004
Present:
L. Bingham of CornhillB. Hale of Richmond
L. Lord Hope of CraigheadL. Carswell
L. Walker of Gestinghorpe 
The Lord Bingham of Cornhill in the Chair.

    The Order of Adjournment is read.

    The proceedings of yesterday are read.

    The Committee deliberate.

    Counsel and Parties are again called in.

    Mr Burnett heard.

    In part heard and adjourned until tomorrow.

WEDNESDAY 4 FEBRUARY 2004
Present:
L. Bingham of CornhillB. Hale of Richmond
L. Lord Hope of CraigheadL. Carswell
L. Walker of Gestinghorpe 
The Lord Bingham of Cornhill in the Chair.

    The Order of Adjournment is read.

    The proceedings of yesterday are read.

    The Committee deliberate.

    Counsel and Parties are again called in.

    Mr Gordon heard

    Mr Burnett heard in reply.

    Further and fully heard.

    Bar cleared; and the Committee deliberate.

    A draft Report is laid before the Committee by the Lord Bingham of Cornhill.

    The Report is considered and agreed to unanimously.

    Ordered, That the Lord Bingham of Cornhill do make the Report to the House.

    Ordered, That the Committee be adjourned.

    

 
previous

Lords Parliament Commons Search Contact Us Index

© Parliamentary copyright 2004
Prepared 10 March 2004