On 21 June 2023, the Supreme Court handed down judgement in R (on the application of Maguire) (Appellant) v His Majesty’s Senior Coroner for Blackpool & Fylde and another (Respondents), the appeal of an inquest into the death of a vulnerable woman subject to a Deprivation of Liberty Safeguards (“DoLS”) order.
In a unanimous decision, the Supreme Court dismissed the appeal, determining that Article 2 of the European Convention on Human Rights (“ECHR”) was not engaged at the inquest.
Background
Jackie Maguire, a woman with Down’s Syndrome, was a resident in a care home for adults with learning difficulties. She lacked the mental capacity to make decisions surrounding her health and welfare and was subject to a DoLS, pursuant to a Standard Authorisation under the Mental Capacity Act 2005.
In the weeks preceding her death, Jackie became increasingly unwell. On 21 February 2017, as her symptoms worsened, an ambulance was called to the care home. She was assessed by paramedics, who sought advice from an out-of-hours GP after Jackie refused to go to hospital. It was concluded that though it was preferable for Jackie to be admitted to hospital, the circumstances did not appear to be serious enough to warrant taking her there against her will.
By the following morning, Jackie’s condition had significantly deteriorated and she was taken to hospital. On the evening of 22 February 2017, Jackie suffered a cardiac arrest and sadly died. The causes of her death were later determined to be pneumonia and perforated gastric ulcer leading to peritonitis.
Inquest
Article 2 of the ECHR provides that the state has a positive obligation to take appropriate steps to safeguard the lives of those in its jurisdiction. This includes having appropriate legal and administrative systems in place for general protection (“systems duty”), and taking operational steps to protect specific individuals at a pressing risk to life (“operational duty”). Article 2 also imposes procedural obligations, such as investigating potential breaches of these duties and providing redress and punishment where necessary.
The Coroner opened an inquest into Jackie’s death on 3 August 2017. Her family argued that due to the circumstances surrounding her death, the inquest should satisfy the enhanced procedural obligation under Article 2, and as such the Coroner should direct the jury to give an expanded conclusion in accordance with section 5(2) of the Coroners and Justice Act 2009. This would mean a conclusion ascertaining the circumstances in which Jackie came to her death rather than simply considering how, when and where she died.
However, the Coroner decided on 29 June 2018 that an expanded conclusion was not necessary. This followed R (Parkinson) v HM Senior Coroner for Kent, a case which established that individual negligence does not fall within the scope of Article 2. In light of this, the Coroner concluded that the allegations against those involved in Jackie’s care would constitute individual negligence, and therefore did not invoke Article 2. The jury was hence directed to give a standard conclusion stating only the cause of death, and concluded that Jackie died as a result of natural causes.
Judicial Review Claim and Appeal
Jackie’s mother, Mrs. Muriel Maguire, brought a judicial review claim challenging the conclusion decision. She sought a declaration that the Coroner had erred in law and Article 2 was engaged, on the grounds that the state had an obligation to Jackie as a vulnerable person under its care. It was also argued that there was evidence indicating systemic issues that violated the state’s systems duty by leading to inadequate medical interventions, which ultimately resulted in Jackie’s death.
The Administrative Court rejected the claim, clarifying that the failures on which Mrs. Muriel’s claim was relying were the result of individual actions or shortcomings, incapable of demonstrating a wider systemic failure. The Court determined that the Coroner’s conclusion decision was free from legal error, as he reasonably concluded that a jury could not safely attribute Jackie’s death to any action or omission for which the state would be held accountable.
The subsequent appeal was dismissed by the Court of Appeal on 12 June 2020. On 23 February 2022, Mrs. Maguire was granted permission to appeal to the Supreme Court.
Supreme Court Judgement
The appeal was heard on 22 and 23 November 2022, and considered the issues of whether there was an arguable breach of the systems duty or the operational duty on the part of the care home or any of the healthcare providers, so as to trigger the enhanced procedural obligation.
With regard to the systems duty, the Supreme Court determined that at the time of the conclusion decision the Coroner was entitled to conclude that there was no arguable breach. The Coroner’s findings regarding the care home were supported by evidence, including the assessment by the Care Quality Commission (“CQC”), which confirmed the presence of appropriate systems at the home. In the judgement, at paragraph 159, Lord Sales highlighted that the CQC’s satisfaction with the systems of the care home usually serves as “powerful evidence that the systems duty has been satisfied.”
Similarly, the Supreme Court identified no error in law regarding the Coroner’s determination that the system within which the ambulance paramedics operated was appropriate and effective. While certain individual errors were acknowledged, it was found that they were not indicative of a systemic inadequacy. Lord Sales clarified in paragraph 146 of the judgement that “individual lapses in putting a proper system into effect are not to be confused with a deficiency in the system itself.”
In the judgement, at paragraph 145, Lord Sales highlighted the limited scope of this Article 2 obligation, stating that “the systems duty in this area operates at a high level, is relatively easily satisfied, and it will only be in rare cases that it will be found to have been breached.”
The Supreme Court also held that there was no arguable breach of operational duty under Article 2. In the judgement, at paragraph 190, in reference to individuals within care homes, Lord Sales stated:
“[the state’s operational duty] does not involve an assumption of responsibility extending to taking responsibility for all aspects of their physical health, with the consequence that if he or she dies from some medical condition which was not diagnosed and treated in time the state’s duty is engaged and the enhanced procedural obligation in terms of accountability is triggered. Even though the individual may not be at liberty, the state is not for that reason made the guarantor of the adequacy of healthcare provided to them in all respects, with an enhanced obligation to account if things go wrong.”
In applying the operational duty to the care home staff, the Supreme Court held that the carers took appropriate steps to seek medical advice and call an ambulance on 21 February 2017. This was in accordance with their responsibility to ensure that Jackie had access to the healthcare available to the population generally.
In relation to the decision not to take Jackie to hospital, the Supreme Court concluded that it did not constitute a breach of the operational duty on the part of the healthcare providers. This was on the basis that none of the medical professionals involved were on notice that Jackie was subject to risk of death, and the paramedics provided a reasonable assessment in the circumstances.
Ultimately, the Supreme Court rejected the submission that the enhanced procedural regulation applied on the basis of an arguable breach of the systems and operational duty.
The Court made a clear distinction between those deprived of liberty for the purpose of ‘familial care’ as authorised by a DoLS, and involuntary detainees such as prisoners or those detained under the Mental Health Act. In the judgement at paragraph 148(4), Lord Sales stated that “in a care home or a nursing home, loss of liberty is an incidental feature of the vulnerability of the individual resident, and it is the vulnerability and the assumption of responsibility of care in the light of it which is the fundamental basis for the duties owed under article 2.” It was emphasised that a vast number of people share Jackie’s vulnerable characteristics and are subject to a DoLS, in their best interests. This context can be contrasted with that of imprisonment, where there is a “heavy onus on the authorities to account where a death occurs.” It was therefore clarified that the circumstances in which Jackie’s death could invoke Article 2 were particularly limited.
Conclusion
The Supreme Court judgement has offered valuable guidance on the specific circumstances in which Article 2 of the ECHR may be engaged.
Significantly, the ruling has provided clarity regarding the distinction between care home residents subject to a DoLS and other vulnerable groups deprived of liberty, such as prisoners. It has been highlighted that the burden on the state to account for deaths differs significantly in these situations, and the obligations imposed by Article 2 should reflect this distinct context.
Given the frequency of encountering Article 2 in coronial proceedings, this decision holds great importance in establishing a clear understanding that a substantial threshold must be reached before its application.
