inquest Archives - Parklane Plowden

Expertise

Our Expertise

Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat.

REPLAY: Inquest Law with Lunch | 10 September 2025

<iframe width="560" height="315" src="https://www.youtube.com/embed/NKblx3whSQ4" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen=""></iframe>   PLP's Abigail Telford and Sophie Watson hosted a Inquest Law with Lunch event on the 10th September 2025. They discuss ‘Unlawful Killing and Neglect’, a subject they recently explored at our Inquest Grandstand in July.

Leila Benyounes to speak at British Orthopaedic Association (BOA) Congress in Liverpool

The <a href="https://www.boa.ac.uk/boa-annual-congress-2025.html">BOA Annual Congress</a> is taking place from 16 September in Liverpool under the theme of ‘Preventing Harm and Saving Lives’.  Leila is on the faculty for the Law for Orthopaedic Surgeons: Avoiding Jeopardy course, and will speak at a session on Coronial Law and Evidence at the Coroner’s Court followed by running a Mock Inquest for delegates.  Leila Benyounes is Head of the Inquests Team at Parklane Plowden Chambers and is ranked by Legal 500 and Chambers and Partners for Inquests and Inquiries and Clinical Negligence. Leila is appointed as an Assistant Coroner in two coronial areas and Leila regularly represents interested persons in a wide range of inquests including Article 2 jury inquests and complex medical matters. She has a special interest in obstetric, birth injury and fatal cases providing representation at inquest and in clinical negligence claims. She has been appointed to the Attorney General Regional Civil Panel Band A since 2010. Her full profile can be accessed <a href="https://www.parklaneplowden.co.uk/barristers/leila-benyounes">here</a>.

Suspicious deaths of those detained in care homes: what amounts to an arguable breach of the operational duty under Article 2?

Since the availability of non-means tested legal aid for Article 2 inquests, it will be important for those representing bereaved families to identify at an early stage whether an inquest is likely to engage Article 2. Similarly, with the potential for the coroner or jury to return a conclusion that criticises the acts or omissions of interested persons, state bodies need to be aware of the circumstances when an Article 2 inquest might arise. The paradigm examples where it is engaged are suspicious deaths whilst detained in prison or whilst detained in a psychiatric unit under the Mental Health Act 1983. These have been described as cases in which Article 2 will automatically be engaged, and thus an Article 2-compliant inquest is required.  This article explores the jurisprudence to date in relation to deaths in care homes, where residents are similarly deprived of their liberty under the Mental Capacity Act 2005. The focus is on the state’s operational duty, as opposed to the wider systems duty, under Article 2 of the ECHR. In addition to practitioners preparing to represent bereaved families at inquests, this article will be relevant to:  <ul class="wp-block-list"> <li>local authorities exercising their powers to detain people in care homes under the Mental Capacity Act 2005; and</li>  <li>commissioning local authorities and NHS integrated care boards when deciding to place someone in a particular care or nursing home.</li> </ul>  Cases where an Article 2 inquest is required  In R (Morahan) v HM Assistant Coroner for West London [2021] EWHC 1603 (Admin), Popplewell LJ conducted a thorough exploration of the domestic and Strasbourg jurisprudence regarding the operational duty under Article 2 and the circumstances in which an Article 2-compliant inquest must be held.  Automatic Categories  There are certain categories of deaths which have been held as automatically engaging Article 2, including:  <ul class="wp-block-list"> <li>killings by state agents;</li>  <li>suicides or attempted suicides and unlawful killings in custody;</li>  <li>suicides of conscripts; and</li>  <li>suicides of involuntary mental health detainees.</li> </ul>  This is not an exhaustive list. Popplewell LJ held that the touchstone for whether the circumstances of a death are such to give rise to a duty to conduct an Article 2-compliant inquest is “whether they fall into a category which necessarily gives rise, in every case falling within the category, to a legitimate ground to suspect state responsibility by way of a breach of a substantive article 2 obligation” (at [122]).  Accordingly, not all deaths in state detention automatically engage Article 2. For example, in Tyrrell v HM Senior Coroner for County Durham and Darlington [2016] EWHC 1892 (Admin), the High Court held that an Article 2 inquest was not required for a death in prison arising out of natural causes, where there was no evidence of negligence or systemic failings by the prison or medical staff.  To date, there has been no authority that defines a category of deaths in care homes that would automatically trigger an Article 2 inquest.  Arguable breach of a substantive duty For cases that do not fall into one of the “automatic categories”, an Article 2 inquest will still be required if there has nonetheless been an arguable breach of one of the state’s substantive duties under Article 2. As we have been recently reminded in R (Ferguson) v HM Assistant Coroner for Sefton, Knowsley & St Helens [2025] EWHC 1901, the “arguability” threshold is a low one. Hill J cited Popplewell LJ in Morahan as to the reason why the threshold is low: “This threshold is a low one because to impose a more onerous burden would run the risk of the coroner determining, in advance of the full evidential picture, what the outcome of any inquest might be” (at [75]).  As to what would satisfy the test, Popplewell went on to say: “… it must amount to more than mere speculation. There must be a real evidential basis which make the suggestion of a breach of a substantive obligation by the state a credible one” (at [75]). “… different expressions (grounds to suspect, legitimate suspicion, possibility, potential, more than fanciful, credible suggestion) are, in my view, simply alternative ways of expressing a single concept of a single threshold of arguability. It is a concept similar to the domestic test for summary judgment, keeping in mind that in the article 2 investigative duty context the test often falls to be applied at an early stage when the evidence is all in the hands of the state authorities” (at [102]).  Hill J in Ferguson has confirmed that the test applies not only to assessing whether the state might have breached a substantive duty, but also assessing whether the state owed a duty under Article 2 in the first place (at [124]-[130]).  The operational duty, the Rabone 'indicia', and medical cases  The state has an operational duty under Article 2 where the state knows, or ought reasonably to know, of a real and immediate risk to an individual’s life, and it requires it to take such measures as could reasonably be expected of it to avoid such risk (Osman v United Kingdom [1998] 29 EHRR 245 at [115]-[116]).  The Supreme Court in Rabone v Pennine Care NHS Foundation Trust [2012] UKSC 2 considered whether an NHS Trust owed the operational duty to a voluntary psychiatric patient. Melanie Rabone had committed suicide whilst on a visit home, when she was known to the NHS Trust to be a high risk of suicide. The Supreme Court held that the operational duty was owed to take steps to protect the deceased from the suicide risk, and that duty had been breached. Lord Dyson when on to set out the “indicia” from Strasbourg authorities which can point to the existence of the operational duty:  <ol class="wp-block-list"> <li>There is a real and immediate risk to the individual’s life;</li>  <li>There has been an assumption of responsibility by the state for the individual’s welfare and safety, including by the exercise of control (paradigms being where the state has detained an individual, such as in prison or in a psychiatric hospital);</li>  <li>The individual is especially vulnerable by reason of their physical or mental condition (in some cases, where the individual is sufficiently vulnerable, there does need to be an assumption of control by the state); and</li>  <li>There is an exceptional risk to life, beyond an “ordinary” risk of the kind that individuals should be expected to take.</li> </ol>  In Rabone, the deceased was an in-patient of the NHS Trust due to her risk of suicide. She was vulnerable due to her mental state, and the NHS Trust had assumed responsibility for her. Whilst not formally detained, the NHS Trust would have been able to prevent her from leaving the hospital using its powers under the Mental Health Act. In essence, the deceased’s case was effectively the same as that of a detained individual in a psychiatric hospital.  The operational duty in the medical context has been further explored in Strasbourg. In Centre for Legal Resources on behalf of Câmpeanu v Romania [2014] ECHR 789, a young man who had been diagnosed with a severe learning disability and HIV had been under the care of the state throughout his life. He displayed challenging needs, and he was transferred to several placements prior to his death. The deceased was transferred to a specialist medical and social care centre that was not equipped to deal with his mental health needs. It was unable to cope with his challenging behaviour, and he was transferred to a hospital for psychiatric treatment. The hospital, however, was unable to treat those with HIV. The decision to place the deceased at the care centre and latterly the hospital seemed to have been based on their willingness to admit him, rather than their ability to meet his needs. Further, the state was found to be aware of the poor conditions at the hospital, including a lack of heating, adequate food, medical staff, and medications. The risk to life was known because there had been several other deaths at the same hospital in similar circumstances to that of the deceased. Accordingly, the Court found that the operational duty was engaged and had been breached.   In Lopes de Sousa Fernandes v Portugal (2018) 66 EHRR 28, it was iterated that something more than “mere medical negligence” was required for Article 2 to be engaged. The case concerned a man who died from septicaemia and the alleged failure by his treating clinicians to provide appropriate treatment. Although the Grand Chamber was discussing the systems duty, the two exceptional circumstances when Article 2 would be engaged were framed in a way which appear to draw parallels with the operational duty:  <ol class="wp-block-list"> <li>“where an individual’s life is knowingly put in danger by a denial of access to life-saving emergency treatment… It does not extend to circumstances where a patient is considered to have received deficient, incorrect or delayed treatment” (at [191]).  </li>  <li>“where a systemic or structural dysfunction in hospital services results in a patient being deprived of access to life-saving emergency treatment and the authorities knew or ought to have known about that risk and failed to undertake the necessary measures to prevent that risk from materialising…” (at [191]).</li> </ol>  It was held that neither of those situations applied to the deceased, and that it was more a case of medical negligence. The court also noted, however, that: “different considerations arise in certain other contexts, in particular with regard to the medical treatment of persons deprived of their liberty or of particularly vulnerable persons under the care of the State, where the State has direct responsibility for the welfare of these individuals” (at [163]).Fernandes de Oliveira (2019) 69 EHRR 8 considered the operational duty in the context of a voluntary in-patient in a psychiatric hospital who committed suicide. As in Rabone, the duty was held to exist. It was noted that the deceased was vulnerable due to his severe mental health problems and that, despite being a voluntary patient, the hospital had the power to exercise control over him over the course of his treatment. However, the Grand Chamber held that the authorities did not know, nor reasonably could have known, that there was a real and immediate risk of suicide. On that basis, the duty had not been breached.  Finally, in Morahan, Popplewell LJ was considering whether the operational duty arose in the context of a voluntary psychiatric in-patient in a community rehabilitation unit, such that an Article 2 inquest was required. Tanya Morahan had paranoid schizophrenia and died from multiple drug toxicity during a period of agreed leave. The deceased had initially been detained under the Mental Health Act, but latterly that had been rescinded, and she remained on the ward voluntarily. She had been allowed to leave the ward previously and had returned, albeit she was late as she had decided upon an impromptu trip to Munich during her leave. It was held that there was no arguable existence nor breach of any operational duty by the state:  <ol class="wp-block-list"> <li>The deceased died because of an accidental overdose. There was no evidence that the NHS Trust was aware, or ought to have been aware, of that risk to her life. There was no history of accidental overdose or suicide attempts, and the deceased had been abstinent from taking drugs.</li>  <li>There was no assumption of responsibility in respect of life-threatening substance misuse. The NHS Trust’s responsibility was in respect of treating her paranoid schizophrenia, which had a history of exacerbation with substance misuse. The treatment had been successful such that detention under the Mental Health Act was no longer required.</li>  <li>She was not especially vulnerable such that it gave rise to the existence of a duty. The case was distinguishable from other cases involving psychiatric patients and a risk of suicide. The deceased’s vulnerability stemmed from her paranoid schizophrenia and, it was held, her risk of accidental overdose was unconnected to that.</li>  <li>Her risk of accidental overdose was no different to that of any recreational drug user. It was therefore not an “exceptional” risk.</li>  <li>Unlike in Rabone, there was no evidence that the NHS Trust had sufficient grounds to detain her if she tried to leave. The level of control was therefore absent.</li> </ol>  From the above, the Rabone indicia continue to be the relevant factors to consider when considering both the existence and breaches of the operational duty by state agencies. It has typically arisen in the context of mental health patients who are at known risk of suicide and are effectively detained. The assumption of responsibility must relate to that known risk, rather than some other risk of death unconnected to the reason for their detention in the first place. Outside of mental health and suicide risk, the duty may be engaged where the state has assumed responsibility for one’s basic healthcare, but knowingly puts the individual’s life at risk by placing them in a setting that is ill-equipped to meet those needs.  Care Homes  The following cases have specifically explored when the operational duty applies in the context of care homes. Similar themes to those from the medical cases arise.  Dodov v Bulgaria (2008) 47 EHRR 41  Mrs Stoyanova, a 63-year-old woman with advanced Alzheimer’s disease, was residing in a nursing home due to her needing constant supervision and care. She was taken to a medical appointment by a staff member but, after leaving her for a few minutes, she had wandered off. She was declared missing and, by the time of the hearing in Strasbourg 11 years later, she still had not been found. The Court assumed that she had died, for the purposes of Article 2. It does not appear to have been argued that the care home owed the deceased an operational duty (presumably because they were not aware of a real an immediate risk to her life, but rather a more general risk of her absconding). It was held that the actions of the care home were comparable to allegations of medical negligence, and the Court focused on the availability of remedies for the same. No violations of Article 2 were found in respect of the care home.  Nencheva v Bulgaria (48609/06, 18 June 2013)  This case concerned 15 children and young adults who had been placed in a specialist care home for those with severe mental disabilities. They had been placed there by the state and required intensive care. They died over the winter of 1996/97 due to being subjected to extremely poor conditions in the care home. This included insufficient food, medicines, and heating. Managers at the care home had notified state officials at the highest levels, but no action was taken for several months. It was held that the operational duty did arise: the state was aware of the real and immediate risk to the lives of these children and young adults. They had failed to promptly intervene to mitigate against that risk.  Dumpe v Latvia (71506/13, 16 October 2018)  AP was a young man with Down’s syndrome and had been placed in a care home by the state. His mother alleged that the staff at the care home, particularly the medical staff, failed to provide adequate care to him. She alleged that he became weaker and lethargic in the months before his death. Three days before his death, the care home called for an ambulance due to the deceased being feeble and unwilling to eat. On admission to hospital, it was noted that the deceased was undernourished, had extensive psoriasis rashes, and was catatonic. During his admission, it was noted that he had hepatitis B, his skin conditions had likely been present for six months, and that he appeared neglected, hypotrophic, and having extreme asthenia. A criminal investigation into his death found that the deceased had died due to cardiac insufficiency, triggered by cardiomyopathy. Whilst some criticism was made of the care home for the delay in seeking medical assistance, a panel of experts had found that it was not possible to say the extent to which this had impacted on the outcome.  The Court held that Article 2 was not engaged. The complaints raised by the deceased’s mother were more akin to allegations of medical negligence. There was no suggestion that the state had unreasonably put the deceased’s life in danger by placing him in the care home (unlike in Câmpeanu and Nencheva). There was no allegation of systemic failings and the care did not fall within the very exceptional circumstances from Lopes de Sousa Fernandes. Accordingly, the complaint was not upheld.  R (on the application of Maguire) v HM Senior Coroner for Blackpool & Fylde [2023] UKSC 20  Outside of Strasbourg, Maguire considered the care provided to a 52-year-old lady with Down’s syndrome and learning difficulties. Jackie lived in a residential care home and was deprived of her liberty there, pursuant to a standard authorisation granted by the local authority. She died as a result of a perforated gastric ulcer and pneumonia. The family’s criticisms of the care home were that there were signs that the deceased was becoming unwell (she was not eating well, had a sore throat, and had diarrhoea) and they were not promptly acted upon by care staff. In brief, they did not seek medical assistance soon enough. When they eventually contacted her GP, the Deceased had become very unwell. They were (wrongly) advised that a home visit was not needed. The care home then contacted 111 the same day and paramedics attended. They wanted to take the deceased to hospital, but she refused. After consulting an out-of-hours GP, it was decided that the deceased would not be compulsorily taken to hospital. The following day, the deceased’s condition deteriorated, the paramedics attended again and on this occasion she was taken to hospital. She sadly died the same day after suffering cardiac arrest.  The Supreme Court specifically considered whether the operational duty was arguably owed by the care home, citing the Rabone indicia. It held that:  “When an individual is placed in a care home, a nursing home or a hospital the state’s operational duty in the targeted sense derived from Osman… 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…” (at [190]).  It was emphasised that a specific risk to life needs to be identified. Whilst it could be argued that the deceased was vulnerable and the state had assumed responsibility for her care generally, it was not until she became very unwell that it could be said that the care home were aware of a real and immediate risk to life. The Supreme Court indicated that, had they taken no steps to seek medical advice at that stage, “that might well have constituted a breach of the article 2 operational duty” (at [204]). The suggestion is, therefore, that if a care home becomes aware that a resident is seriously unwell, the operational duty will be engaged to the extent that they should be seeking medical advice.  Validity Foundation on behalf of TJ v Hungary [2024] ECHR 796  TJ was a woman with a severe learning disability who had been placed in a care home by the state. She lacked capacity to make decisions regarding her health and welfare for herself, and she had been appointed a guardian to make such decisions. She was known to display challenging behaviour and was not allowed to leave the care home.  Prior to her death, the care home in which the deceased resided had been investigated by a team of monitors from the Validity Foundation. It produced a damning report, highlighting instances of unlawful use of restraint, lack of proper heating, malnutrition, and neglect. The Ministry for Human Resources then carried out its own investigation into the care home and corroborated the concerns raised by the Validity Foundation.  It found that the care home was extremely understaffed and that restraint was being used to mitigate the risk of residents, like TJ, from suffering falls and displaying aggressive behaviour. It further found that the care home could not achieve the minimum standard of living conditions. The Hungarian Commissioner for Human Rights also produced a report, which concluded that the care home lacked adequate care facilities and that human rights were being violated.  TJ was taken to hospital in August 2018, where she was diagnosed with bacterial pneumonia. She suddenly deteriorated and died before discharge. The Court agreed with the findings of the Validity Foundation that TJ’s condition had been triggered by long-term neglect at the care home.  The Court cited Nencheva and Câmpeanu in finding that Article 2 was engaged. The state was clearly aware of the appalling conditions in which TJ had been detained, and had not taken adequate protective measures to mitigate against the risk of death. In addition, it held that the state had assumed responsibility for her health and welfare, and TJ was under their exclusive control. She needed constant supervision, was unable to make decisions for herself, and she was not free to leave the care home. The Court held that it was incumbent on the state to account for TJ’s medical treatment and give appropriate explanations regarding the care she received.  Practice points  Although there is no authority that suggests that Article 2 will automatically be engaged when there is a death in a care home, the jurisprudence confirms that there will be circumstances where the operational duty will be engaged.  The Rabone indicia continue to be relevant considerations, and it can be anticipated that they can apply in a care home setting:  <ol class="wp-block-list"> <li>If the care home or the state more generally is aware of a real and immediate risk of death, the duty can be engaged. These could include: <ul class="wp-block-list"> <li>Where the individual is seriously unwell (which should have been apparent to non-medical care staff) and the care home fail to seek medical assistance (Maguire). This would also be comparable to the first exceptional circumstance when Article 2 is engaged in a medical context from Lopes de Sousa Fernandes: a denial of access to emergency life-saving treatment.</li>  <li>Where the state is aware, or ought to have been aware, that the care home was incapable of meeting the individual’s basic care needs, such that their life was at risk (Nencheva, TJ).</li> </ul> </li>  <li>For any resident to be detained in a care home under the Mental Capacity Act 2005, it will be because it is necessary and in their best interests. They must lack capacity to agree to the detention. Such residents are therefore likely to be regarded as vulnerable, by virtue of their physical and/or mental state.</li>  <li>By being so detained, the state will have assumed responsibility for their health and welfare in the general sense. The individual will not be free to leave and are effectively under the state’s control (TJ, Nencheva). However, assuming control over their health and welfare does not trigger a duty under Article 2 necessarily (Maguire). Arguably negligent care will not be sufficient (Dumpe, Dodov) and it should be shown that the state agency was aware (or ought to have been aware) of a specific risk to life (Maguire).</li> </ol>  As in the medical context, it seems likely that it will only be rare that a breach of the operational duty will be found regarding care home deaths. However, for an Article 2 inquest, the court is only concerned with whether it is arguable that there has been. When considering if a death in a care home arguably engages Article 2, the following will be relevant to the coroner’s investigation:  <ul class="wp-block-list"> <li>Is there any evidence to suggest that the care home resident was seriously unwell and care staff failed to seek any medical attention? Applying the obiter comments in Maguire, this would suggest an arguable breach.</li>  <li>Is there any evidence that the state agency knew or ought to have known that the care home was not safe to meet the individual’s basic needs? For example, is there a damning CQC report? Have there been any safeguarding investigations conducted by the local authority? Was there a deterioration in the individual’s overall condition that would not be attributable to their age or a health condition that led to their placement in a care home? If the individual was placed in the care home despite there being serious concerns about its ability to meet their basic needs, it would be arguable that Article 2 is engaged (Nencheva, TJ).</li> </ul>  Tom is a member of the inquests team and is recognised by the Legal 500 and Chambers & Partners as a leading practitioner in this field. His practice is complimented by his experience in clinical negligence, Court of Protection, and community care. He has represented various interested persons in inquests, including bereaved families, local authorities, NHS Trusts, individual practitioners, and insurers. He regularly appears in Article 2 inquests and those sitting with a jury. His full profile can be accessed <a href="https://www.parklaneplowden.co.uk/our-barristers/tom-barclay-semple/">here</a>.

Karen Boyle Appointed Assistant Coroner

Chambers are delighted to announce that <a href="https://www.parklaneplowden.co.uk/our-barristers/karen-boyle/">Karen Boyle</a> has been appointed as an Assistant Coroner for Nottingham City and Nottinghamshire.  The role is part time and Karen continues to practice from Parklane Plowden Chambers where she accepts instructions in the specialist areas of Inquests, Personal Injury, Clinical Negligence and Employment.  Chambers would like to congratulate Karen on her new appointment.

Jury finds shortcomings, flaws and missed opportunities in care of detained patient: Leila Benyounes acts in Article 2 Inquest

Leila Benyounes represented the Family of Donna Levin in an Article 2 inquest at Teesside Coroner’s Court presided over by the Senior Coroner for Teesside and Hartlepool, Ms Clare Bailey, sitting with a jury.  Donna, who was a much loved 54-year-old mother of three and special educational needs teacher, was admitted to Roseberry Park Hospital on 28 December 2019 following increased concerns for her safety by her Family. She had been struggling with her mental health for a few months and had been diagnosed with obsessive compulsive disorder. Donna died on 8 January after being found unresponsive in her room at the hospital on 4 January 2020 whilst she was detained under the Mental Health Act.  Following a seven-day inquest during which fourteen live witnesses gave evidence, the jury found that there were shortcomings, flaws and missed opportunities in the care provided to Donna.  The jury found that key risk information was not included in a verbal handover from day staff to night staff or recorded in the electronic medical records, some of which were amended after events. These shortcomings meant that Donna’s risk levels were not amended in a risk assessment, and there was no change to the minimum hourly level of observations and engagements, which should have been increased.  After Donna asked to leave the ward to kill herself, and Donna was detained under the Mental Health Act, the jury found that there was no further assessment to take into account Donna’s further deterioration. Planned hourly checks were not undertaken, the observation sheet was falsely completed, and there were several missed opportunities in the doctor seeing Donna. Significantly, the jury found that the risk management plan and risk safety were not updated appropriately.  In concluding that Donna died by suicide due to suffering from a mental illness, the jury found that the risks of encouraging sleep to support long term treatment did not outweigh the risk of ensuring short term safety and the risks should have been further considered until the doctor saw Donna.  Links to local news articles:  <a href="https://www.thenorthernecho.co.uk/news/25351119.family-stockton-teacher-donna-levin-release-statement-inquest/">Family of Stockton teacher Donna Levin release statement after inquest</a>  <a href="https://www.gazettelive.co.uk/news/teesside-news/donna-levin-roseberry-park-death-32162956">Family’s ‘painful clarity after clear shortcomings’ in bubbly mum’s care at Roseberry Park Hospital</a>  <a href="https://www.gazettelive.co.uk/news/teesside-news/donna-levin-inquest-roseberry-park-32151354">Jury retire in inquest into ‘full of joy’ teacher allegedly failed by Roseberry Park Hospital</a>  <a href="https://www.thenorthernecho.co.uk/news/25339276.staff-missed-check-patient-roseberry-park-hospital/">Staff missed check on mum at Roseberry Park Hospital before tragedy</a>  Ms Benyounes was instructed by Lois Hepworth of Watson Woodhouse Solicitors.  Leila Benyounes is Head of the Inquests Team at Parklane Plowden Chambers and is ranked by Legal 500 and Chambers and Partners for Inquests and Inquiries and Clinical Negligence. Leila is appointed as an Assistant Coroner in two coronial areas and Leila regularly represents interested persons in a wide range of inquests including Article 2 jury inquests and complex medical matters. She has a special interest in obstetric, birth injury and fatal cases providing representation at inquest and in clinical negligence claims. She has been appointed to the Attorney General Regional Civil Panel Band A since 2010. Her full profile can be accessed <a href="https://www.parklaneplowden.co.uk/barristers/leila-benyounes">here</a>.

Fiat accompli? R (Campbell) v HM Attorney General for England and Wales [2025] EWHC 1653 (Admin)

There are two ways of reading the judgment in <a href="https://www.judiciary.uk/wp-content/uploads/2025/07/Campbell-v-Attorney-General.pdf">R (Campbell) v HM Attorney General for England and Wales [2025] EWHC 1653 (Admin)</a>.  For those who are fans of legal theory, there is a meticulous examination of the role and functions of the Attorney General. The Divisional Court considered his functions (for it is currently a “he”) relating to criminal law (such as consenting to certain prosecutions, dealing with contempt of court, and appeals against unduly lenient sentences) and civil law (for example, in relation to vexatious litigants and special advocates). It conducted a detailed examination of the limitations on the justiciability of his decisions. It concluded with a carefully reasoned decision, ultimately refusing permission to apply for judicial review.  For everyone else, there’s paragraph 56.  The question  Mr Campbell’s brother, Geoffrey, was killed when the North Tower of the World Trade Centre collapsed on 11th September 2001. HM Senior Coroner for West London held an inquest in January 2013, in which she recorded that an aircraft was flown into the building as part of Al-Qaeda’s co-ordinated attack, thereby causing its collapse.  Mr Campbell does not accept that the building collapsed due to the impact of the aircraft. He believes it was caused by the detonation of pre-planted explosives or incendiaries.  Section 13(1)(b) of the Coroners Act 1988 permits the High court to quash an inquisition and direct a fresh investigation (or a first investigation, where none has been held). Before doing so, the High Court must be satisfied either that the coroner has refused or neglected to hold an inquest or an investigation which ought to be held, or that it is necessary or desirable in the interests of justice to hold another investigation where the first was tainted by fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, the discovery of new facts or evidence or otherwise. The application to the High Court must be made by or under the authority or "fiat" of the Attorney General.  Mr Campbell accordingly applied to the Attorney General for authority to apply to the High Court. It was refused.  Mr Campbell sought judicial review of that refusal. It was said that the Attorney General (in fact, the Solicitor General who made the decision on his behalf) had erred in law, made a decision which was irrational and unreasonable, and had failed to give adequate reasons. The Summary Grounds of Defence asserted that the challenged decision was not justiciable at all (or alternatively was challengeable only on exceptional grounds, such as fraud, corruption or bad faith).  The answer  The short answer is that the Attorney General’s decision was not justiciable. Permission to apply for judicial review was refused.  The slightly longer answer involves consideration of authorities stretching back to 1855. The courts developed the clear position that decisions taken by the Attorney General in the exercise of his “public interest” functions were not justiciable in proceedings seeking the prerogative writ of mandamus (the forerunner to modern judicial review). If the Attorney General was answerable to anyone, it was to Parliament.  A key case was Gouriet v Union of Post Office Workers[1978] AC 435. Broad observations were made in that case by the House of Lords as to the courts’ lack of jurisdiction to review the Attorney General’s decisions. Gouriet concerned the Attorney General’s refusal of consent to bring relator proceedings (actions brought by private individuals in the Attorney General’s name, in order to enforce a public right), but the principle is not confined to such proceedings. In R v Attorney General ex p. Ferrante (unreported, 1st July 1994) it was said that Gouriet is of general application, and that whether or not a decision is amendable to judicial review depends on its nature and subject matter.  The Divisional Court concluded that the authorities demonstrated that there is a class of discretionary functions of the Attorney General “whose exercise [are] categorically immune from review”. That class includes the Attorney General’s powers to enforce the law by bringing criminal or civil proceedings in the public interest, and powers to authorise or terminate such proceedings by others. The function in section 13(1)(b) of the 1988 Act is one such power.  Accordingly, the refusal of consent was not justiciable, and it was not open to Mr Campbell to seek judicial review of it.  In the alternative, the Divisional Court said that if the decision had been justiciable, then the only grounds for review would have been dishonesty, bad faith or an exceptional circumstance (none of which applied in this case).  The future?  This is not a decision which appears to have been reached with any degree of enthusiasm.  The Divisional Court noted that the identification of a category of decisions as immune from review on any grounds appears “anomalous”. The fact that the Attorney General is accountable to Parliament, said the Court, “hardly distinguishes those decisions from many others which today would certainly be justiciable” (paragraph 47). In paragraph 54, the Court noted that it must be for a higher court to say if the principle in Gouriet is no longer good law in relation to the Attorney General’s powers. The combined effect of existing authority “is that it is not now open to any court below the Supreme Court to decide otherwise, however anomalous this may seem in the light of the rest of the modern law of judicial review”.  One to watch.  Peter Yates is part of the Inquests Team at Parklane Plowden. Peter's profile can be accessed <a href="https://www.parklaneplowden.co.uk/our-barristers/peter-yates/">here</a>.

10th September 2025 | Inquest Law with Lunch

The next webinar in our ‘Law with Lunch’ series of bitesize, lunchtime talks covering legal issues of the moment is not to be missed.  Wednesday 10th September 2025 | 12:30 – 13:30  Join two members of Parklane Plowden's Inquest team, Abigail Telford and Sophie Watson as they discuss 'Unlawful Killing and Neglect', a subject they recently explored at our Inquest Grandstand in July.  Please register via <a href="mailto:events@parklaneplowden.co.uk" target="_blank" rel="noreferrer noopener">events@parklaneplowden.co.uk</a>.

Case Report: R (On the application of Jada Bailey) v HM Senior Coroner for East London [2025] EWHC 1637 (Admin)

Jaden was an individual who had been killed on 8 January 2019. An inquest to his death was formally opened on 18 January 2019. The inquest process was then overtaken by the criminal proceedings which took place, and the inquest was adjourned on 2 April 2019. Ayoub Majdouline was convicted of Jaden’s murder and sentenced to life imprisonment with a minimum term of 21 years on 18 December 2019.  On 24 December 2019, the Coroner issued a certificate that the inquest was not to be resumed. The Claimant applied to the Coroner to resume the inquest in June 2023 and a decision not to resume the inquest was issued in a document dated 18 March 2024. Jaden’s mother, Jada Bailey (the “Claimant”), sought to judicially review that decision on three points:  <ul class="wp-block-list"> <li>The decision not to resume the inquest gives rise to a breach of the procedural obligation under ECHR Article 2;</li>  <li>The Coroner’s conclusion not to resume the inquest rested on two errors of law as to the likely utility of the resumed inquest; and</li>  <li>The decision was contrary to a duty to investigate arising at common law (this was abandoned in submissions as there is no separate common law source of either power or obligation for a Coroner to investigate – they are statutory under the Criminal Justice Act 2009). This was then adapted that the Coroner had failed to have regard to relevant considerations, namely: <ul class="wp-block-list"> <li>the public interest in holding an inquest;</li>  <li>the purpose pursued by sections 5(1) and (2) of the 2009 Act;</li>  <li>that an inquest can serve to allay any public concern arising from a death; and</li>  <li>the possibility of making a regulation 28 report.</li> </ul> </li> </ul>  The decision not to resume the inquest gives rise to a breach of the procedural obligation under ECHR Article 2  The Coroner had accepted the Claimant’s basic premise that there was an obligation to investigate under ECHR Article 2. In the usual course of inquests, the holding of an inquest discharges the investigative duty as required under the provisions of the 2009 Act. The Coroner in this case had considered that the investigative duty had been discharged already by the time the Claimant had sought to resume the inquest, as a Serious Case Review had been commissioned by the Safeguarding Children’s Board for Waltham Forest, published in May 2020.  The Claimant’s submitted that there were concerns regarding the scope and content of the SCR report; there were criticisms regarding the form of the investigation; the author of the SCR report lacked independence; the Claimant did not have sufficient opportunity to be involved in the SCR exercise; and it did not meet the requirement for public scrutiny. Further, following the SCR report, complaints raised about the conduct of the Metropolitan Police had not been properly addressed in an investigation by the Independent Office for Police Conduct.  As to the SCR report, Swift J commented:  It is readily apparent from the SCR report that it is a thorough and thoughtful consideration of all relevant matters. To my mind the SCR report is a highly impressive piece of work that should provide valuable assistance to all public authorities concerned. By identifying very clearly things they did and things they failed to do the SCR report ought both to promote accountability for what happened and to provide valuable guidance to those public authorities as regard their future conduct. Whenever considering a document such as this SCR report it will always be possible to point to further questions that could have been considered or further detail that could have been looked for. But that is not the test of whether the investigation that has been undertaken meets the requirement arising under article 2. In the circumstances of this case the investigation needed to consider the actions of the public authorities in Nottinghamshire and in London that had responsibilities that, if performed, would have served to safeguard C against the risk of falling victim to criminal exploitation. The SCR report, as written, evidences an effective investigation of the actions and omissions of those public authorities.  …  The purpose of an article 2 investigation is to consider what did happen; to establish a picture of past events. Often it will be readily apparent from findings on what did happen, what other steps should have been taken. That is so in the present case since it is clear from the SCR report that certain steps that were not taken should have been taken. But that is a by-product of the investigation.  Swift J considered that there was no principle reason why the SCR report, and the way in which the investigation had been conducted, was incapable of satisfying the article 2 duty to investigate. Swift J found that the author of the SCR report was independent and there was no suggestion that the investigation was not independent either. There was no requirement for an inquest to compel witnesses to give evidence or for certain documents to be provided, and so the argument that the SCR process did not do this had to fall away.  As to the lack of public scrutiny, Swift J held:  The requirement arising from article 2 for sufficient public scrutiny of either the investigation or its results or both, exists to ensure accountability, to promote public confidence in adherence to the substantive obligations arising under article 2, and to prevent any appearance of collusion or tolerance of unlawful acts. What is appropriate to meet these objectives is not fixed. There is no requirement that an investigation must be conducted through public hearings. I do not consider that the investigation that Mr Drew undertook was impaired by the absence of such hearings. Considered in the round, the SCR report identifies and then scrutinises the acts and omissions of the relevant public authorities.  Moreover, as to the lack of the Claimant’s involvement:  Given the factual circumstances… “I do not consider any of this shows that the Claimant was insufficiently involved in the investigation or lacked an effective opportunity to participate in and comment on the formulation of the SCR report. Rather, opportunities to participate were available from the outset of the investigation in early 2019 and, given the assistance available to the Claimant from the experienced and able solicitors who advised her, the opportunities to participate were real and substantial.”  The Coroner’s conclusion not to resume the inquest rested on two errors of law as to the likely utility of the resumed inquest  The Claimant submitted that the Coroner had failed to consider a narrative conclusion in their decision and their comments in relation to regulation 28 reports indicated a misdirection on the law.  As to the first point, Swift J remarked:  The suggested distinction between "short-form" and "narrative" conclusions that is the premise of this submission is a distinction without a difference. There is no material difference between a conclusion expressed using any of the terms listed in Note (i) and one that is in the "brief narrative" form anticipated by Note (ii). Each is intended to be descriptive: to describe the outcome of the inquest. For example, a conclusion of "unlawful killing" could be given either by simply using those words or through a narrative to the same effect.  The Coroner had referred to regulation 28 reports as ‘toothless’, and whilst Swift J considered that this was a rather colourful description; the Coroner had not misdirected himself on the law in relation to regulation 28 reports; and therefore this ground also failed.  Failure to have regard to relevant considerations  Swift J found that the Coroner did have regard to the possibility of making a regulation 28 report and that reading the decision in the round it had specifically considered and took the relevant considerations into account. This ground therefore failed.  Takeaways and practice points  The most interesting part of this decision is that the duty of the State to investigate does not have to be via the traditional inquest route and can be discharged via different avenues – there is no automatic right to an inquest. If other investigations have taken place in/around an incident one must take a holistic view of everything and consider whether it meets the article 2 duty; if so, there may not be a need for an inquest.  Bharat Jangra is part of the Inquests Team at Parklane Plowden. Bharat’s profile can be accessed <a href="https://www.parklaneplowden.co.uk/our-barristers/bharat-jangra/">here</a>.

Avoidable Baby Death: Leila Benyounes Represents the Family at Inquest

Leila Benyounes represented the Family of a baby that died aged 1 day old in an 11 day inquest in Bradford. Leo Luca Thomson was born on 13 November 2018 at the Calderdale Royal Hospital in Halifax.  HM Assistant Coroner Peter Merchant found that Leo’s birth at 34 weeks’ gestation arose due to concerns from a cardiotocograph trace (CTG) indicating Fetal Bradycardia. There was a delay in escalating concerns regarding the CTG trace to a Doctor which in turn led to a delay in the decision to perform a Category 1 Caesarean Section. Further, when the decision to perform the Category 1 Caesarean Section was taken, a maternity theatre was not immediately available. This resulted in a delay of up to 9 minutes in Leo's delivery.  It was found that earlier delivery would have avoided a corresponding period of neurologically damaging acute profound hypoxic ischaemia such that with the prompt and effective resuscitation that he was given, would, on the balance of probabilities have led to Leo's survival.  It was also found that there were failures in Leo’s mother’s care in the days preceding Leo’s birth and she should have been diagnosed with a premature rupture of membranes on 12 November 2018, which would have led to an earlier admission to hospital.  Despite prompt and effective resuscitation Leo had suffered Irreversible Hypoxic Ischaemic  Encephalopathy (HIE). Tragically, baby Leo was transferred to Forget Me Not Hospice in  Huddersfield on the day after his birth and he died there.  The inquest heard evidence from 15 witnesses including three independent expert witnesses in midwifery, obstetrics and neonatology.  The local news article can be accessed <a href="https://www.examinerlive.co.uk/news/west-yorkshire-news/mistakes-delays-yorkshire-maternity-unit-31868155">here</a>.  Ms Benyounes was instructed by Fay Russell of <a href="https://www.switalskis.com/">Switalskis</a>.  Leila Benyounes is Head of the Inquests Team at Parklane Plowden Chambers and is ranked by Legal 500 and Chambers and Partners for Inquests and Inquiries and Clinical Negligence. Leila is appointed as an Assistant Coroner in two coronial areas and Leila regularly represents interested persons in a wide range of inquests including Article 2 jury inquests and complex medical matters. She has a special interest in obstetric, birth injury and fatal cases providing representation at inquest and in clinical negligence claims. She has been appointed to the Attorney General Regional Civil Panel Band A since 2010. Her full profile can be accessed <a href="https://www.parklaneplowden.co.uk/barristers/leila-benyounes">here</a>

Missed opportunities by Police to Secure Appropriate Mental Health Support for 35 Year Old Father Talked Down from Railway Bridge

Bronia Hartley represented the family of a 35 year old father who took his life at a homeless hostel where he was left by police officers 20 minutes after being talked down from a railway bridge, from which he had intended to jump.  The inquest heard that Dean Bradley was expressing persecutory beliefs and appeared paranoid and delusional. Body Worn Video disclosed Mr Bradley pleading with officers not to be returned to the homeless hostel due to his delusional belief that people staying there were going to kill him.   Following his death Mr Bradley was found to have an excessive amount of prescribed antidepressant medication in his system but no alcohol or drugs of abuse.  HM Senior Coroner for Teesside and Hartlepool, Clare Bailey, found that the officers, who did not contact mental health services before leaving Mr Bradley at the homeless hostel, made “dangerous assumptions” about his presentation and failed to secure appropriate mental health support for him.   The Coroner issued a Prevention of Future Deaths report detailing concerns regarding safeguarding pending mental health assessment where the individual is believed to be intoxicated.  Bronia was instructed by Lois Hepworth of <a href="https://www.watsonwoodhouse.co.uk/">Watson Woodhouse Solicitors</a>.  Bronia Hartley is part of the Inquests Team at Parklane Plowden. Bronia’s profile can be accessed <a href="https://www.parklaneplowden.co.uk/our-barristers/bronia-hartley/">here</a>.  Reporting: <a href="https://www.bbc.com/news/articles/c20xzld3g47o">BBC</a>

Latest News

Video

18 September 2025

REPLAY: Inquest Law with Lunch | 10 September 2025

Read time: < 1 m

Event

18 September 2025

21 October 2025 | Navigating Financial Remedies: A Lunchtime Briefing

Read time: < 1 m

News

18 September 2025

Leila Benyounes to speak at British Orthopaedic Association (BOA) Congress in Liverpool

Read time: < 1 m

Event

15 September 2025

01 October 2025 | Court of Protection Grandstand

Read time: < 1 m

Cookie	Duration	Description
cookielawinfo-checkbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.

Your Shortlist (0)

Our Expertise

REPLAY: Inquest Law with Lunch | 10 September 2025

Leila Benyounes to speak at British Orthopaedic Association (BOA) Congress in Liverpool

Suspicious deaths of those detained in care homes: what amounts to an arguable breach of the operational duty under Article 2?

Karen Boyle Appointed Assistant Coroner

Jury finds shortcomings, flaws and missed opportunities in care of detained patient: Leila Benyounes acts in Article 2 Inquest

Fiat accompli? R (Campbell) v HM Attorney General for England and Wales [2025] EWHC 1653 (Admin)

10th September 2025 | Inquest Law with Lunch

Case Report: R (On the application of Jada Bailey) v HM Senior Coroner for East London [2025] EWHC 1637 (Admin)

Avoidable Baby Death: Leila Benyounes Represents the Family at Inquest

Missed opportunities by Police to Secure Appropriate Mental Health Support for 35 Year Old Father Talked Down from Railway Bridge

Latest News

REPLAY: Inquest Law with Lunch | 10 September 2025

21 October 2025 | Navigating Financial Remedies: A Lunchtime Briefing

Leila Benyounes to speak at British Orthopaedic Association (BOA) Congress in Liverpool

01 October 2025 | Court of Protection Grandstand