Jacqueline Maguire died in hospital after becoming seriously ill at her care home. Her mother challenged the form of the inquest verdict. The issue was whether the evidence disclosed an arguable breach of the state’s duty to protect life under Article 2, requiring the jury to address the circumstances of death in greater detail.
Jacqueline Maguire (“Jackie”), aged 52, had Down’s Syndrome, learning disabilities and limited mobility. From 1993 she lived in a privately run care home for adults with learning difficulties, funded and supervised by the local authority. The home was registered with the Care Quality Commission. She was not free to leave unsupervised, and a standard authorisation under the Mental Capacity Act 2005 deprived her of liberty in her best interests. She lacked capacity to decide about her medical care and was fearful of medical interventions. She died in hospital on 22 February 2017 from pneumonia and a perforated gastric ulcer with peritonitis.
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Care-home staff contacted medical services as Jackie’s condition worsened. When paramedics attended, she resisted going to hospital. They and an out-of-hours GP judged that the use of restraint or sedation was disproportionate and advised monitoring. Her condition deteriorated overnight and she was taken to hospital the following morning. The inquest heard expert evidence both about the risk she had faced and about what the professionals could reasonably have understood at the time.
The coroner opened the inquest on the footing that an expanded verdict might be required, heard extensive evidence, and then ruled that Article 2 did not require one. The jury returned a short-form verdict of death from natural causes. Jackie’s mother sought judicial review. The Divisional Court and the Court of Appeal upheld the coroner. The Supreme Court appeal concerned only the form of the verdict.
Article 2 and the form of an inquest verdict
Article 2 requires the state to protect life. Its substantive positive obligations include a systems duty to maintain appropriate legal and administrative arrangements, and an operational duty to take reasonable preventive steps where the authorities know or ought to know of a real and immediate risk to an identified person’s life. The procedural obligation to investigate is graduated. In some situations, including an arguable breach of a substantive duty, an enhanced investigation is required. Section 5(2) of the Coroners and Justice Act 2009 then requires the inquest to ascertain the circumstances as well as the means of death. In ordinary allegations of medical negligence, a conventional inquest together with the possibility of a civil claim satisfies the state’s procedural obligations. Individual errors are not themselves a systems failure, and the coroner who has heard the evidence is primarily responsible for deciding whether an arguable breach has been shown.
No arguable breach of the systems duty
Lord Sales, with whom Lord Reed, Lord Lloyd-Jones and Lady Rose agreed, held that the coroner was entitled to find no arguable systems breach by the care home or the healthcare providers. A regulatory regime supervised by the Care Quality Commission, together with the home’s own recording, handover and training arrangements, met the systems duty. The same was true of the arrangements governing the ambulance service and other healthcare providers. Failures to pass on information, or imperfect clinical judgments, were individual lapses rather than defects in the system. The very exceptional circumstances identified in the Strasbourg case law — knowing denial of life-saving emergency treatment, or a systemic dysfunction of which the authorities knew or ought to have known — were not present. A protocol requiring sedation whenever Jackie resisted hospital was not a point properly open on the appeal, and in any event a system that leaves room for professional judgment in the circumstances is not deficient.
No arguable breach of the operational duty
The operational duty is targeted at a specific risk of which the state is or ought to be aware; it does not make the state a guarantor of all aspects of a detained person’s physical health. Care-home staff, who were not medically trained, sought medical advice and an ambulance when Jackie became seriously unwell and were entitled to rely on the advice they received. None of the healthcare professionals was on notice that her life was in danger if she was not taken to hospital that evening. Their assessment that restraint or sedation was not then proportionate took account of her presentation, her autonomy and the risks of force. Expert evidence did not condemn that judgment. By the close of the evidence there was therefore no arguable breach capable of triggering the enhanced procedural obligation.
Lord Stephens agreed that the appeal should be dismissed. He emphasised Jackie’s total dependence on others for decisions about hospital treatment, and cautioned against adding a domestic gloss to the Strasbourg test of a real and immediate risk, while accepting that the coroner’s conclusion was justified on the evidence.
Verdict: The Court unanimously dismissed the appeal. On the evidence heard at the inquest there was no arguable breach requiring an expanded verdict. The jury’s short-form finding of death from natural causes stood.
