Recent years have seen dramatic changes in the way in which deaths in custody are investigated, as the state has struggled to comply with its obligations under Article 2 of the European Convention on Human Rights – the so called 'Right to Life'. This timeline draws together legislative, legal and political developments which now govern the way in which these controversial deaths are investigated. Bhatt Murphy is proud of the contribution that it has made to progressive developments in this important area but there is much work still to be done in improving the transparency, openness and effectiveness of these investigations.
1988 Coroners Act
The
Act sets out the legislative framework within which Coroners exercise their powers to investigate controversial deaths. The Act is now significantly out of date and is causing practical difficulties for Coroners in their endeavours to meet their modern obligations under Article 2 of the European Convention on Human Rights.
28.09.1990 UN Basic Principles on the Use of Force and Firearms by Law Enforcement Officials
The
Principles sets out minimum standards for the thorough, prompt and impartial investigation of controversial deaths in custody, including the entitlement of the deceased's family to effective access to the investigation. Adopted by the Eighth United Nations Congress on the Prevention of Crime and the Treatment of Offenders, Havana, Cuba.
06.04.1994 Restraint related death of Richard O’Brien
Restraint related death of Richard O’Brien in custody of Metropolitan Police.
16.12.1994 Restraint related death of Shiji Lapite
Restraint related death of Shiji Lapite in custody of Metropolitan Police.
1995 Court of Appeal imposes a narrow remit for Coroners and their juries
In Humberside Coroner ex parte Jamieson [1995] QB 1, the Court of Appeal held that the Coroner’s remit was a narrow one limited to considerations of merely ‘how’ the deceased came by his death; and that a finding of neglect was only appropriate in the most extreme of circumstances and were direct causation had been established. In the same judgment, the Court of Appeal also held that the duty of the Coroner was to 'ensure that the relevant facts are fully, fairly and fearlessly investigated … He must ensure that the relevant facts are exposed to public scrutiny'. The tension between the two aspects of the judgment has led to real difficulty in its practical application for many years.
1995 The Gibraltar Case
In the groundbreaking case of
McCann and others v UK 1995 21 EHRR 1997, the ECtHR held that Article 2 requires some form of effective investigation when individuals have been killed or injured as a result of the use of force by agents of the state. The investigation must consider the planning and organisation lying behind those actions.
10.11.1995 Unlawful killing verdict on Richard O'Brien's death in custody of Metropolitan Police
Following a two week inquest exploring the circumstances of the restraint related death of Richard O’Brien on 6 April 1994, the inquest jury took just 40 minutes to return a unanimous verdict that he had been unlawfully killed. The Coroner, Sir Montague Levine, referred the case back to the DPP for further consideration and castigated the training provided by the Metropolitan Police to its officers in restraint techniques.
08.12.1995 Restraint related death of Alton Manning
Restraint related death of Alton Manning in custody of HMP Blakenhurst.
25.01.1996 Unlawful killing verdict on Shiji Lapite's death in custody of Metropolitan Police
Following a two week inquest, the jury returned a unanimous verdict of unlawful killing in respect of the death of Shiji Lapite on 16 December 1994 as a result of a neck hold applied by police officers following his arrest – they insisted that they had never been warned about the fatal dangers inherent in the use of a neckhold, despite guidance to that effect having been circulated by ACPO to all police forces in January 1994.
16.03.1996 Restraint related death of Ibrahima Sey
Restraint related death of Ibrahima Sey in custody of Metropolitan Police.
1997 Article 2 Requires Identification and Punishment
In
Aydin v Turkey 1997 25 EHRR 251, the ECtHR held that the obligation on the state to ensure a thorough and effective investigation into a death in custody required that the next of kin should have effective access to the investigatory procedure, and that it should be capable of leading to the identification and punishment (where appropriate) of those responsible for the death.
1997 DPP judicially reviewed for failures to prosecute police officers
The widows of Shiji Lapite and Richard O’Brien together with Derek Treadaway (who had established at trial before a High Court judge that he had been tortured in police custody) launch judicial review of the failure of the Director of Public Prosecutions (DPP) to prosecute police officers.
22.07.1997 DPP concedes her decision not to prosecute in the Lapite case was unlawful
On the first day of the trial of the Lapite-O'Brien-Treadaway judicial review proceedings, the DPP conceded that she could no longer defend the decision not to prosecute the officers concerned in the death of Shiji Lapite.
23.07.1997 DPP concedes her decision not to prosecute in the O’Brien case was unlawful
On the second day of the trial, the DPP was forced to concede that she could no longer defend the decision not to prosecute the officers involved in the O’Brien case, having been compelled to disclose an internal memorandum which revealed that the decision had been based on a consideration of the police accounts alone, to the exclusion of other eye witness accounts.
31.07.1997 High Court finds the DPP's decision in the Treadaway case to be unlawful
Lord Justice Rose ruled in a detailed judgment that the DPP’s reasoning and conclusions leading to the decision not to prosecute the officers in the Treadaway case demonstrated a flawed approach involving a repeated failure to give the close scrutiny, careful consideration and proper appraisal demanded by the available evidence.
08.1997 Butler Inquiry established
In the wake of the judicial review challenges to the DPP's decisions in the cases of Lapite, O'Brien and Treadaway, the Attorney General sets up independent inquiry by HH Judge Gerard Butler QC into the handling of deaths in custody and other serious cases within the Crown Prosecution Service under the DPP - and in the interim the DPP was stripped of her powers in relation to decision making in such cases.
02.10.1997 Unlawful killing verdict on Ibrahima Sey's death in custody of Metropolitan Police
Following a five week inquest, the jury returned a unanimous verdict of unlawful killing in respect of the restraint related death of Ibrahim Sey on 16 March 1996 – highlighted the dangers of positional/restraint asphyxia and the use of CS spray in relation to a person who is mentally ill.
16.12.1997 Report of the Home Affairs Select Committee on Police Complaints and Discipline
Home Affairs Select Committee condemns the arrangements for investigating deaths in custody.
1998 Osman v UK
Osman v UK 29 EHRR 245 ECtHR
25.03.1998 Unlawful killing verdict on Alton Manning's death in the custody of HMP Blakenhurst
Following a four week inquest, the jury return a unanimous verdict of unlawful killing in respect of the death of Alton Manning in the custody of HMP Blakenhurst on 8 December 1995 as a result of a neckhold applied by prison officers in the course of restraint.
20.05.1998 DPP Resigns
The DPP resigns, significantly weakened by criticism from the courts and the Butler Inquiry following her own forced admissions of flawed decision making .
1999 Coroners (Amendment Rules) 1999
Sets out matters to be ascertained at inquests, use of evidence and prevention of similar fatalities.
29.04.1999 Home Office issue circular on pre-inquest disclosure
The Home Office issue Circular 20/1999 - 'Deaths in Custody: Guidance to the Police on Pre-inquest Disclosure' - encouraging pre-inquest disclosure of relevant documents to bereaved families in cases of deaths in police custody. The guidance does not establish any legal entitlement to disclosure which remains the responsibility of the police. See below (2002) for a copy of the current guidance.
06.1999 Criminal prosecution and trial of police officers involved in unlawful killing of Richard O'Brien
Prosecution and trial of police officers for the manslaughter of Richard O’Brien culminates in their acquittal.
11.08.1999 Publication of Butler Report
Butler Report published following independent inquiry into CPS decision making and handling of deaths in cutody and pother serious cases.
2000 ACPO Family Liaison Strategy
ACPO (Association of Chief Police Officers of England, Wales and Northern Ireland) launches its Family Liaison Strategy, outlining standards of good practice and recognising the crucial role to be played by the bereaved family in a successful investigation.
28.03.2000 Mahmut Kaya v Turkey
Mahmut Kaya v Turkey ECtHR
Article 2(1) requires the state not only to refrain from the intentional and unlawful taking of life, but also to take appropriate steps to protect life.
17.05.2000 Entitlement to reasons for decisions not to prosecute
R v DPP ex parte Manning and Melbourne [2000] EWHC Admin 342.
Bereaved families gain entitlement to reasons for CPS decisions not to prosecute officers of the state in relation to deaths in custody and other serious violations.
02.10.2000 Human Rights Act 1998 comes into force
2001 Jordan v UK
Jordan v UK [2001] 37 EHRR 52
The ECtHR sets out the Jordan Criteria for the minimum standards to be achieved by any effective official investigation into a death, with regard to the obligations of the state under Article 2 with reference to securing of evidence, promptness of inquiry and the role of next of kin.
12.01.2001 Attorney General's review of the role and practices of the CPS in cases of deaths in cutody
The Attorney General announces a review of the role and practices of the Crown Prosecution Service in cases of death in custody.
2002 Police Reform Act
Police Reform Act 2002 establishes the Independent Police Complaints Commission to oversee the police complaints process and to conduct an independent investigation for the most controversial of cases including most deaths in police custody.
2002 Proposal for independent investigation of prison deaths
In its White Paper, Justice for All, the Government proposed that the remit of the Prisons & Probation Ombudsman be extended to include investigating deaths in prison custody.
04.2002 Consultation paper on Attorney General's review
Publication of
Consultation Paper on Attorney General’s review of the role and practices of the Crown Prosecution Service in cases of deaths in custody.
06.2002 Response to Attorney General's consultation paper
Response of Bhatt Murphy (with INQUEST & LIBERTY) to Attorney General's consultation paper on his review of the role and practices of the Crown Prosecution Service in cases of deaths in custody.
05.06.2002 Revised Home Office circular on pre-inquest disclosure
Deaths in Police Custody: Guidance to the Police on Pre-Inquest Disclosure.
Home Office Circular 31/2002 revises the guidance given to police on the provision of pre-inquest disclosure to bereaved families in cases of deaths in police custody
03.2003 The Shipman Inquiry Report
The Shipman Inquiry reports on death certification and coronial investigation systems.
06.2003 Report of the Fundamental Review of Death Certification and Coronial Investigation Systems
04.07.2003 Coroner must investigate systemic police failings
Hurst v HM Coroner for Northern District of London.
The Divisional Court holds that Article 2 requires an effective investigation of systemic failures that may have contributed to the death even though there had been a criminal trial which had determined how the deceased had come by his death. See below (2005) with regard to the Commissioner's unsuccessful appeal to the Court of Appeal on this case which is currently pending a further appeal to the House of Lords.
16.07.2003 Attorney General's report on review of the CPS
Attorney General’s Report upon his review of the role and practices of the Crown Prosecution Service in cases of deaths in custody. See also:
Response of Bhatt Murphy and others to the Attorney General’s Review.
08.2003 First independent investigation into death in prison custody
The deaths of six women at HMP Styal in the preceding 12 month period leads to the first independent investigation into a death in prison custody.
The Prisons & Probation Ombudsman is asked to conduct an investigation into the last of this series of tragic deaths, and also to identify any themes which emerge. This call comes in advance of his office being given a standing commission to investigate all such deaths. Bhatt Murphy is instructed in respect of 2 of these controversial deaths.
03.10.2003 Unlawful killing verdict on Roger Sylvester's death in custody of Metropolitan Police
Following an inquest hearing over 5 weeks, the jury return a unanimous verdict of unlawful killing in respect of the restraint related death of Roger Sylvester in January 1999 – highlighting yet again the dangers of positional/restraint asphyxia and the use of restraint on mentally ill members of the public– see the family campaign at
www.rsjc.org.uk.
16.10.2003 Family wins entitlement to a public inquiry
R v Secretary of State for the Home Department ex parte Amin [2003] UKHL 51.
The House of Lords rules on the entitlement of a bereaved family to an independent and public judicial inquiry in a case concerning the failure of the Prison Service to prevent a death in its custody, applying the Jordan minimum criteria under Article 2.
11.2003 MPA review of police restraint techniques
Metropolitan Police Authority set up a review of restraint techniques and officer safety training, with particular reference to the treatment of individuals suffering from mental illness, in light of the jury verdict of unlawful killing in respect of the death of Roger Sylvester.
11.03.2004 Coroners' inquests required to extend focus to systemic failings
R (Middleton) v West Somerset Coroner [2004] 2 AC 182; and
R (Sacker) v West Yorkshire Coroner [2004] UKHL 11.
The House of Lords rule that the requirement in section 11(5)(b)(ii) of the Coroners Act 1988 and Rule 36 (1)(b) of the Coroners Rules 1984 to determine "how the deceased came by his death" should be interpreted as meaning not simply "by what means the deceased came by his death" but "by what means and in what circumstances the deceased came by his death" in order to meet the requirements of an Article 2 compliant investigation.
11.03.2004 Section 6 of the Human Rights Act 1998 does not apply to pre-HRA deaths
Re McKerr
House of Lords rule that section 6 of the Human Rights Act 1998 does not apply to deaths occurring before 2 October 2000, i.e. the coming into force of the 1998 Act.
01.04.2004 Prison and Probation Ombudsman assumes investigative responsibilty for prison deaths
The Prisons & Probation Ombudsman formally assumes responsibility for investigating all deaths in prison or probation custody, or in immigration detention. The role is an administrative one as he does not currently have statutory powers, although these are currently the subject of a Bill. In any case, his remit is limited to making recommendations and not to enforcing these. It is intended that this new independence will help to ensure that inquiries into such deaths are compliant with Article 2 of the ECHR, in that they are effective and transparent and encourage active participation by bereaved families.
01.04.2004 IPCC commences operation
The Independent Police Complaints Commission assumes responsibility for the investigation of deaths in police custody and complaints against police, with powers to conduct their own independent investigation in most cases of deaths in custody.
09.2004 Review of restraint techniques
Metropolitan Police Authority approve and publish
report upon review of restraint techniques and officer safety training, with particular reference to the treatment of individuals suffering from mental illness, in light of the jury verdict of unlawful killing in respect of the death of Roger Sylvester.
17.11.2004 Coroner's jury identifies systemic failings
Inquest returns damning verdict in case of
Anna Claire Baker, one of the HMP Styal deaths referred to above.
25.11.2004 Unlawful killing verdict quashed
R (Anderson and others) v HM Coroner [2004] EWHC 2729 (Admin)
Roger Sylvester Family Statement
High Court quashes unlawful killing verdict in respect of restraint related death of Roger Sylvester in police custody.
2005 Expanding entitlement to pre-inquest disclosure in custodial death cases
Prisons and Probation Ombudsman develops
policy on disclosure for deaths in custody.
The guidance highlights good practice to ensure compliance with the state’s obligations under Article 2.
29.05.2005 Section 3 of the Human Rights Act does apply to pre-HRA deaths
Metropolitan Police Commissioner v Hurst [2005] EWCA Civ 890
The Court of Appeal held that section 3 of the Human Rights Act (on interpreting Acts of Parliament to comply with Convention rights) applies to deaths that occurred before the HRA and therefore the House of Lords’ interpretation of the Coroner’s Act in Middleton and Sacker (see above) applied to this case and there should be an effective investigation of not only how the deceased came by his death but also ‘in what circumstances’.
Re McKerr distinguished. The case is currently pending a further appeal by the Commissioner to the House of Lords.
01.2006 ACPO protocol investigating deaths in prison
ACPO publish
protocol for police investigation of prison, probation and immigration related deaths in custody – the result of the outcome of a formal complaint by the family of Alton Manning concerning the serious and systemic failures in the West Mercia police investigation of his restraint related death in the custody of HMP BLakenhurst.
06.01.2006 Prison Service issues PSO 2710
Prison Service issues
PSO 2710 detailing the responsibilities it will discharge following a death in custody.
06.02.2006 Ministerial statement on reform of the coroners' system
Minister of State at the DCA Harriet Harman MP set out the government's long awaited proposed reform of the inquest system. A draft Bill should be available in April/May 2006 with a view to the proposed legislation being announced in the Queen's Speech in November with the hope of a new Coroners Act in 2007.
Explanatory note and Minister's statement
