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.
16.09.2013 Mark Duggan inquest begins
The inquest into the death of Mark Duggan begins today in the High Court before HHJ Cutler. It is expected to last 6-8 weeks. Nogah Ofer and Carolynn Gallwey have been involved in this case.
05.07.2013 Azelle Rodney Inquiry Report published
Mr Rodney died on April 2005 after being shot six times by Metropolitan Police Service officers. The judicial inquiry found that the Authorised Firearms Officer who fired the fatal shots had "no lawful justification" for opening fire. The case was referred to the Crown Prosecution Service (CPS) to determine whether a prosecution should be launched.
02.07.2013 David Emmanuel suicide verdict
A jury has returned a verdict of suicide in the inquest into the death of reggae artist David Emmanuel, also known as Smiley Culture. It found that Mr Emmanuel died from a self-inflicted stab wound to the heart on 15 March 2011 during a raid on his property by Metropolitan Police officers. Sophie Naftalin acted for the family.
10.05.2013 Inquiry accounced into the death of Daniel Morgan
The Home Secretary, Theresa May, has announced that an Independent Inquiry will be established to examine the circumstances leading to the death of Daniel Morgan in 1987. Sir Stanley Burnton will lead the panel. Raju Bhatt acts for the family of Daniel Morgan.
03.05.2013 Prosecution of officers who restrained Colin Holt
PC Leigh and PC Bowdery were today acquitted of offences of misconduct in public office, following the death by asphyxia of Colin Holt, a mental health patient who they restrained in his home. Mark Scott acts for the Mr Holt’s family.
18.11.2012 Metropolitan Police and police doctor compensate family of man left to die in cell
The family of Andrzej Rymarzak has received the maximum amount of compensation payable in a gross negligence claim following the death of Mr Rymarzak at Chelsea Police Station. The police and the Forensic Medical Examiner Dr Hisham El-Baroudy left Mr Rymarzak dying in a coma on the floor of a cell after deciding that he was fit enough to be detained. The custody sergeant was to face disciplinary proceedings for gross misconduct but retired prior to the hearing. Carolynn Gallwey and Nogah Offer acted for the family.
12.11.2012 Casale review of IPCC Investigation into the death of Sean Rigg
The Independent Police Complaints Commission has today announced an external review of its investigation into the circumstances leading to the death of Sean Rigg at Brixton police station on 21 August 2008. This follows a highly critical Rule 43 report after an inquest was held on 1 August 2012 into Sean’s death. The review will be led by Dr Silvia Casale and will probe the manner in which the IPCC investigates contentious deaths
24.07.2012 High Court challenge to system of investigating deaths in psychiatric detention
An inquest into the death of Mrs Janey Antoniou has found that she died inadvertently on 23 October 2010 in her room at Northwick Hospital. Following criticism of aspects of Janey’s care by the jury, Janey’s husband Dr Michael Antoniou issued a challenge in the High Court regarding the differential way in which deaths in hospitals are investigated in comparison to the deaths of those detained elsewhere. Tony Murphy acts for Dr Michael Antoniou.
19.07.2012 PC Simon Harwood acquitted in the death of Ian Tomlinson
PC Harwood has today been acquitted of causing the death of Ian Tomlinson in April 2009. PC Harwood struck Mr Tomlinson from behind with a baton and pushed him, causing him to fall. Mr Tomlinson collapsed soon after due to internal bleeding and later died. An inquest jury returned a verdict of unlawful death in May 2011.
13.02.2012 Prison Service receives Crown Censure
For only the second time, the Prison Service was formally censured for failing to maintain a safe environment for vulnerable prisoners. Following a death by hanging in a so-called ‘safer cell‘ at HMP Bullingdon, it transpired that the prison had installed shower rails in these cells in contravention of guidance and had failed over some years to identify and correct this. As a result of this case, new requirements for safer cells became mandatory across the prison estate from April 2012.
08.02.2012 Death of Melanie Rabone: civil proceedings
This important case arose from Ms Rabone’s suicide whilst on home leave from an NHS hospital, and offers some useful guidance on the test for a duty of care, the threshold for an Article 2 claim, and concerning issues of limitation and quantum in these cases.
02.02.2012 IPCC to review its Article 2 investigations
The Independent Police Complaints Commission has announced a thematic review into its engagement with Article 2 of the European Convention on Human Rights. It will review its work in this area, focusing on its powers, resources and approach to cases that raise Article 2 issues.
13.01.2012 Prosecution of police doctor for leaving man to die
In January 2009 Dr Hisham El-Baroudy was asked to examine Mr Andrzej Rymarzak, who was in fact unconscious on the floor of a Police cell. Although he was presenting as an acute medical emergency Dr El-Baroudy decided that he was fit for detention. Dr El-Baroudy was acquitted but later faced a disciplinary hearing before the General Medical Council in March 2013, where he was struck off the Medical register.
07.07.2011 Deaths of Iraqi citizens: Al-Skeini v UK
This case concluded that, in exceptional cases, acts performed in a foreign state could come under the jurisdiction of the European Convention on Human Rights. Here, the Article 2 duty to carry out an effective investigation arose in relation to deaths in Iraq as a result of UK action between 1 May 2003 and 28 June 2004 in the same way as if those deaths had occurred in the UK.
30.05.2011 Unlawful killing verdict for Ian Tomlinson
An inquest jury has returned a verdict of unlawful killing in respect of the death of Ian Tomlinson. Mr Tomlinson was making his way home during the G20 demonstrations on 1 April 2009 when he was struck by PC Simon Harwood of the Territorial Support Group and later died of internal bleeding.
30.01.2011 Adam Rickwood inquest verdict
A jury has returned a highly critical verdict following the re-convened inquest into the death of 14 year old Adam Rickwood. The inquest jury found that an unlawful use of force contributed to his decision to take his own life at Hassockfield Secure Training Centre on 8 August 2004. He was the youngest child to die in custody in modern times. Mark Scott acted for Adam’s family.
01.12.2010 House of Lords defeat plan to abolish Chief Coroner
The House of Lords has voted by 275 votes to 165 against the coalition government’s plans to abolish the role of Chief Coroner.
01.11.2010 Coalition to abandon plans for a chief Coroner
The coalition government has announced that it plans to abolish the post of Chief Coroner. The post was introduced by the previous Labour government in order to provide much-needed oversight and consistency in how inquests are run.
27.04.2010 Blair Peach Report Published
The Cass Report into the circumstances of the death of Blair Peach was today released after thirty years of secrecy. Mr Peach was fatally struck by a truncheon or police radio during clashes with the Special Patrol Group at an anti-National Front protest in Southall in April 1979. The Cass Report confirms that a police officer delivered the fatal blow and that the police covered up his actions. Raju Bhatt acted for the Celia Stubbs, Mr Peach’s partner, following the death of Mr Peach.
12.11.2009 Coroners and Justice Act (2009) receives Royal Assent
Key elements of the legislation include the creation of the post of Chief Coroner, who will have oversight over the coronial courts and the introduction of a right of appeal, in certain circumstances, to the Chief Coroner.
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  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
 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
 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
 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
 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
 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
 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  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
 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
 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
 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
 2 AC 182; and
R (Sacker) v West Yorkshire Coroner
 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
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
 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
 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
 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
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
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
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  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
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
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.