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Timeline - Deaths in Custody

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.

Deaths in Custody
15.05.2009 Jack Straw concedes that “secret” inquests plan should be abandoned
The government finally conceded that there was insufficient support for their contentious proposal to certify inquests (ie convene them behind closed doors and without a jury) where sensitive information is likely to be made public. Those provisions will be removed from the Coroners & Justice Bill before it becomes law.
12.05.2009 Joint Committee on Human Rights comes out against “secret” inquests
The JCHR found that the case for secret inquests was not made out by the Government, and that the safeguards they had proposed would be ineffective. They proposed that provisions relating to secret inquests be removed from the Coroners & Justice Bill.
03.04.2009 High Court adopts narrow interpretation of “relevant circumstances” in an Article 2 death
R (Lewis & others) v HM Coroner for the Mid and North Division of the County of Shropshire & others [2009] EWHC 661 (Admin)

These three challenges broadly concerned the issue of whether inquest juries should be allowed to comment on matters of relevance to deaths in custody which may fall outside the legal chain of causation. It was argued that a proper reading of the Article 2 case law allowed for and encouraged findings about the wider circumstances of a death at the hands of the State, but the High Court disagreed, commenting that Article 2 required neither the investigation nor the expression of matters arising out of a death which were not causative or contributory. This decision is currently the subject of an appeal.
25.03.2009 Costs of inquests are recoverable in civil proceedings subject to test of relevance
This Court of Appeal case is an important one for bereaved families, given the restricted funding available for inquests. In it, the court found that costs of attending an inquest can be recovered as incidental costs in civil proceedings arising out of the death, subject to a test of relevance and depending on the case’s circumstances.
22.01.2009 High Court finds use of pain compliance on children is unlawful
R (Carol Pounder) v HM Coroner for the North and South Districts of Durham and Darlington, the Youth Justice Board and others [2009] EWHC 76 (Admin)

This challenge followed the Coroner’s refusal to rule on the legality of the force used on Adam Rickwood on the evening of his death (see above). The High Court concluded not only that the Coroner was wrong to refuse to make such a ruling but that there was no doubt that Adam had been subject to an unlawful assault by staff.
14.01.2009 The Coroners & Justice Bill 2009 is finally tabled

Almost 2 years since announcing that legislative reform of the Coronial system was in train, a draft Bill was finally tabled in the House of Commons. It raises a number of concerns; in particular it proposes secret or “certified” inquests in certain circumstances, but also appears to downgrade the role of juries in some cases and fails to make provision for funding legal representation for bereaved families. INQUEST in particular lobby hard for improvements.
12.12.2008 De Menezes inquest jury returns open verdict
Directed that they could not return a verdict of unlawful killing, the inquest jury return an open verdict on the basis that they did not accept that the officers who fired at Jean Charles de Menezes honestly believed he posed an imminent mortal threat, or that they used reasonable force in the circumstances. They also disbelieved police claims that they had shouted a warning, or that de Menezes had moved towards them when challenged.
10.12.2008 Positive duties to protect life under Article 2 emphasised in mental health suicide case
In Savage v South Essex Partnership NHS Foundation Trust [2008] UKHL 74, Mrs Savage was detained under the Mental Health Act but absconded and committed suicide by throwing herself under a train. The civil claim brought by her daughter led to the House of Lords determining, as a preliminary issue, the test for establishing a breach of Article 2. In doing so, they rejected the Defendant’s submission that the Claimant needed to show gross negligence, and confirmed that, for patients detained under the Mental Health Act, authorities would be expected to do all that was reasonable to protect life where they knew or ought to have known that there was a real and imminent risk of loss of life.

BM were interveners in this case.
26.11.2008 An Article 2 compliant investigation following a prison suicide attempt
In R (JL) v SSJ [2008] UKHL 68, The House of Lords held that it was not necessary to show an arguable breach of the substantive Article 2 obligation to trigger an Article 2 compliant investigation – this case concerned a prisoner whose suicide attempt resulted instead in long-term brain damage. The case was categorised as a ‘near miss’ and it was held that in such cases of severe injury, an Article 2 compliant investigation may well be necessary, although the court also noted that there may be circumstances when it will not.
10.10.2008 Fatal police shootings: Officers should not be permitted to confer
R (Saunders and Tucker) v the IPCC and others [2008] EWHC 2372 (Admin)

The families of two men shot dead by the police challenged the IPCC for their failure to ensure that the police officers involved in the killings were prevented from collaborating in the preparation of their accounts of the shootings. The Court accepted the IPCC position that they had been waiting for guidance to be published by the Association of Chief Police Officers (ACPO) but sent a clear message that the relevant guidance should be finalised. That guidance was published two weeks later. It relates only to deaths by shooting however; in all other deaths following or in the course of police contact, conferring is still permitted.
02.10.2008 The Court recognises a broad definition of “interested persons” to inquests
In R (Platts) v HM Coroner for South East Yorkshire [2008] EWHC 2502 (Admin), The deceased in this case had mental health problems and was detained by police as a result of his bizarre and threatening behaviour. They failed to carry out any assessment of him and he killed himself just after being released from custody. The coroner refused to recognise his girlfriend as an interested person because they had split up shortly before his death. That decision was quashed by the High Court, who confirmed that Coroner’s Rule 20(2)(h) should be interpreted broadly.
30.07.2008 “Real and immediate risk to life” confirmed as threshold for police failure to protect victims
30.07.08 “Real and immediate risk to life” confirmed as threshold for police failure to protect victims

The House of Lords confirmed that the test of whether Article 2 was engaged in cases brought by victims of crime was as set out in Osman v United Kingdom (1998) 29 EHRR 245, namely that there will be a breach of the positive obligation under Article 2 ECHR if the authorities knew or ought to have known at the time of the existence of a real and immediate risk to life, and failed to take appropriate measures. They found that this threshold was not met in the case of these appeals.
28.07.2008 High Court quashes amendments to Rules which extend use of physical force on children in detention
R (C) v Secretary of State for Justice [2008] EWCA Civ 882

Following the controversy around the inquests into the death of Adam Rickwood and Gareth Myatt (see above), the Secretary of State for Justice sought to extend the circumstances in which physical force might be used on detained children. This challenge succeeded on the basis that the amended rules would have infringed the human rights of the children to whom such restraint was to be applied and were contrary to the requirements of Articles 3 and 8 of the ECHR.
26.07.2007 Custody providers can be tried for corporate manslaughter
The Corporate Manslaughter and Corporate Homicide Act 2007 creates the offence of corporate manslaughter for companies and other organisations where gross failures in the management of health and safety have fatal consequences. This will apply to most custodial settings but roll-out will take place over 3 to 5 years. The Government had initially proposed that public authorities – including prisons – be excluded from the ambit of the Act, and this was the subject of fierce debate: see further commentary by Inquest and the Justice Department.
08.06.2007 High Court confirms evidential test for unlawful killing
In R (Cash) v HM Coroner for Northamptonshire [2007] EWHC 1354 (Admin), Darren Cash died following a period of restraint by police. He had taken an overdose shortly beforehand and his family queried whether there was any need to use force on him at all given that he was weak and unwell at that time. The Coroner refused to leave “unlawful act manslaughter” to the jury as a possible verdict and the Cash family challenged that refusal in the High Court. The Court found that it could not be said that there was no evidence on which the jury, properly directed, could have concluded that the degree of force used to restrain Darren Cash was unreasonable or contributed significantly to his death, and the Coroner was therefore wrong not to leave unlawful killing as a verdict. However, following the re-convened inquest, the jury again returned an accidental death verdict.
01.05.2007 Coroner refuses to rule on legality of force used on child in custody
Inquest touching upon the death of Adam Rickwood

Adam Rickwood was the youngest person to die in custody in modern Britain. During the evening before he took his own life, staff at the privately run detention centre restrained Adam for a minor matter using a “pain compliance” technique. Use of such techniques was not permitted by the relevant Rules. In the inquest which followed, the Coroner refused to make a ruling as to whether the type of restraint used on Adam was lawful.
01.05.2007 Coroner refuses to rule on legality of force used on child in custody
Inquest touching upon the death of Gareth Myatt

At 15, Gareth Myatt was the youngest person to die in detention whilst under restraint. He was less than 5 feet tall but was restrained by three prison officers for refusing to clean a sandwich toaster. He died of asphyxia, choking on his own vomit. Concerns expressed about the dangers of the type of restraint used over several years had not led to its use being reviewed by the Youth Justice Board. The technique used was banned after Gareth’s death.
28.03.2007 House of Lords allows police appeal against finding that HRA applies retrospectively
The House of Lords rejected the Court of Appeal’s finding that section 3 of the Human Rights Act (HRA) required the Coroner’s Act to be read in such a way as to comply with Article 2 of the ECHR, in deaths that pre-dated the introduction of the HRA.
17.10.2006 Court of Appeal rejects calls for public inquiry into death of 16 year old Joseph Scholes
R (Scholes) v Secretary of State for Justice [2006] EWCA Civ 1343

Joseph Scholes was a highly vulnerable 16 year old who had been sentenced to 2 years for his passive role in the robbery of 3 mobile phones. In spite of his age, vulnerability and the fact that this was his first custodial sentence he was sent to a Young Offenders Institution. He took his own life 9 days later. The Coroner suggested that wider issues around sentencing and the accommodation of vulnerable child detainees should be the subject of a public inquiry. Joseph’s mother’s request for such an inquiry was refused by the Secretary of State, and that refusal was upheld in this Court of Appeal decision.
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
06.01.2006 Prison Service issues PSO 2710
Prison Service issues PSO 2710 detailing the responsibilities it will discharge following a death in custody.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
06.2003 Report of the Fundamental Review of Death Certification and Coronial Investigation Systems
03.2003 The Shipman Inquiry Report
The Shipman Inquiry reports on death certification and coronial investigation systems.
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
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.
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.
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.
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.
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.
02.10.2000 Human Rights Act 1998 comes into force
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.
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.
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.
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.
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.
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.
1999 Coroners (Amendment Rules) 1999
Sets out matters to be ascertained at inquests, use of evidence and prevention of similar fatalities.
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 .
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.
1998 Osman v UK
Osman v UK 29 EHRR 245 ECtHR
1998 Human Rights Act
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.
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.
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.
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.
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.
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.
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.
16.03.1996 Restraint related death of Ibrahima Sey
Restraint related death of Ibrahima Sey in custody of Metropolitan Police.
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.
08.12.1995 Restraint related death of Alton Manning
Restraint related death of Alton Manning in custody of HMP Blakenhurst.
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.
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.
16.12.1994 Restraint related death of Shiji Lapite
Restraint related death of Shiji Lapite in custody of Metropolitan Police.
06.04.1994 Restraint related death of Richard O’Brien
Restraint related death of Richard O’Brien in custody of Metropolitan Police.
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.
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.
In the timeline an orange heading indicates a contribution from Bhatt Murphy lawyers.
Our Police Misconduct Timeline is also relevant.