Inquest into the death of Olaseni Lewis (2017)
Olaseni (known as Seni) Lewis was 23 years old when he died following prolonged restraint by police officers at the Bethlem Royal Hospital on 31 August 2010. Almost six and
a half years later, the shocking and contentious circumstances of the death will be subject to public scrutiny at South London Coroner’s Court. Raju Bhatt and Sophie Naftalin of
Bhatt Murphy represent the family.
Inquest into the death of Josh Collinson (2016)
An inquest jury concluded that failures on the part of prison and healthcare staff at both HMPYOI Parc and HMPYOI Swinfen Hall contributed to the death of 18 year old Josh Collinson. Mark Scott of Bhatt Murphy acted for the family.
Inquest into the death of Christopher Brennan (2016)
The Coroner at the inquest into the death of 15 year old Christopher Brennan concluded that gross failings constituting neglect contributed to Christopher’s death in Bethlem Hospital Adolescent Unit. Tony Murphy of Bhatt Murphy acted for the Brennan family.
Inquest into the death of Kingsley Burrell (2015)
An inquest jury returned a finding of neglect amidst a raft of other highly critical findings at the inquest into the death of Kingsley Burrell. The CPS has now been asked to consider whether three of the four officers implicated in the death of Mr Burrell on 31 March 2011 have committed any offences arising from the truthfulness of the accounts they gave to the IPCC and under oath at the inquest. They have asked that the IPCC also refer the actions of the fourth officer to the CPS, and that the CPS be asked to reconsider their earlier decision not to bring charges for assault and in relation to the death itself. Carolynn Gallwey of Bhatt Murphy represents Kingsley’s children and their mothers.
Fullick, R (on the application of) v HM Senior Coroner for Inner North London & Anor  EWHC 3522 (Admin)
The Chief Coroner ruled that a jury was required for an inquest into the death of a woman attending a police station to give a victim statement. This was the first judgment under the Coroners and Justice Act 2009 on entitlement to a jury when the deceased was not detained.
Inquest into the death of Cherry Groce (2014)
An inquest jury found that the death of Mrs Dorothy “Cherry” Groce was the result of serious and multiple police failures.
Jimmy Mubenga, a healthy 46 year old Angolan man, died on 12 October 2010 following face-forward restraint in his seat by three G4S security guards on a British Airways flight from Heathrow airport to Angola. Following eight weeks of evidence, the jury at the inquest into his death ruled that he had been unlawfully killed.
The coroner at the inquest published a comprehensive and highly critical report making a series of recommendations to the Home Office and agencies involved.
Inquest into the death of Peter Murphy (2011)
A jury returned a highly critical narrative verdict following the inquest into the death of Peter Murphy.
The death of Mr Murphy aged 21 years at HMP Swansea was contributed to by serious failures and inadequacies on the part of both South Wales Police and HMP Swansea according to the verdict returned at the conclusion of an inquest into his death before HM Coroner for the City and County of Swansea.
R (Carol Pounder) v HM Coroner for the North and South Districts of Durham and Darlington, the Youth Justice Board and others, HC 
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.
R (Lewis & others) v HM Coroner for the Mid and North Division of the County of Shropshire & others, HC 
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.
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.
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.
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.
The House of Lords rejected the Court of Appeal’s finding (see below) 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.
R (Scholes) v Secretary of State for Justice, CA 
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.
Judgment for the Claimants: Intervention on behalf of REDRESS in challenge to the refusal of the Defendant to apply Article 2/3 standards to investigation of civilian deaths at the hands of British soldiers in Iraq, invoking an extension of the jurisdiction of the ECHR and the HRA to those deaths in certain circumstances.
Re Sarah Campbell dec’d 2005
The jury expressed concerns in a narrative verdict about the treatment of Sarah Campbell, one of a number of women to have died at HMP Styal. The Coroner reported that there should be an investigation into the use of segregation in the women’s prison estate.
Jacobs v The Home Office, the Youth Justice Board and the London Borough of Lambeth 2005
Substantial settlement achieved in respect of a mother’s distress occasioned by the state’s failure to protect the life of her son in custody and local authority care.
An important test case concerning retrospectivity under the Human Rights Act. We successfully argued that section 3 of the Human Rights Act (on interpreting Acts of Parliament to comply with Convention rights) should operate to ensure a Convention compliant inquest concerning systemic contributors to the death albeit that the death had occurred before the Act came into force. Re McKerr distinguished. The case itself concerns failures on the part of the Metropolitan Police and others to take steps to protect the deceased who was at risk from a third party. The Commissioner has appealed and the case is now pending before the House of Lords.
Re Roger Sylvester, dec’d. Representation of the family in contesting police officers’ challenge to the inquest verdict of unlawful killing in relation to the restraint related death of Roger Sylvester whilst in the custody of the Metropolitan Police.
Re Doyle, dec’d 2004
A verdict of system neglect in respect of the 7th death in a sequence of 7 suicides amongst Irish prisoners at Brixton prison (see also Gavin and Fegan below). Detailed post-Middleton jury findings.
Re Joseph Scholes, dec’d 2004
Accidental death, with ‘Middleton neglect’. An unprecedented Coroner’s report under rule 43 that there should be a public inquiry Case involving the self inflicted death in custody of a 16 year old young offender where there was multi agency failings.
Re Anna Claire Baker 2004
Narrative verdict pointing to culpability on the part of the Home Office following an inquest into the death of vulnerable woman prisoner at HMP Styal. The inquest jury found that the following factors contributed to the death: inadequate assessment, inappropriate and insufficient detoxification, lack of staff, staff training and funding, lack of communication, poor suicide risk management, and a total lack of awareness and staff training in managing prisoners at risk of self-harm/suicide.
Re Jamie Burton, dec’d 2003
Heroin toxicity contributed to by systemic neglect of Devon & Cornwall police. Jamie died in custody following his ingestion of heroin with systemic failures by the police to operate their policy and procedures and PACE Codes of Practice.
Walters v Chief Constable of Devon & Cornwall 2003
Admission of liability for breach of Article 2 of the ECHR & compensation of £15,000 in respect of the death of an adult child who died in the custody of the state.
C v Metropolitan Police Commissioner, London Boroughs of Haringey, Brent & Ealing, and Central Middlesex & North Middlesex Hospitals NHS Trusts 2003
Substantial settlement achieved in respect of the death of a child aged 8 years at the hands of her carers in circumstances indicating gross neglect of duty on the part of the Defendants.
B v Sunderland City Council and Priority Healthcare Wearside NHS Trust 2003
£25,000 settlement achieved in a claim for damages arising out of the death of a patient with mental health problems who was in the care of the Defendants.
Re Roger Sylvester, dec’d 2003
Inquest verdict of unlawful killing in relation to a restraint related death in the custody of the Metropolitan Police – highlighted yet again the dangers of positional/restraint asphyxia and the use of restraint on mentally ill members of the public.
O’Brien (3) v The Commissioner of the Metropolitan Police 2003
Settlement achieved of damages totalling £324,000 arising from the unlawful killing of Richard O’Brien in police custody.
Re Bishop, dec’d 2003
Verdict of accidental death in respect of an inquest and civil litigation alleging MPS failure to operate safe drug searching practice.
Re Gavin, dec’d 2003
Verdict of system neglect. Inquests and civil litigation arising from the deaths of Irish men at Brixton Prison revealing a pattern of systemic failings on the part of the Prison Service in relation to Irish men detained there.
O’Brien (3) v The Commissioner of the Metropolitan Police 2002
Damages totalling £324,000 in respect of a civil claim aising out of the unlawful killing of Richard O’Brien in police custody.
Re Jacobs, dec’d 2002
Verdict of systemic neglect in respect of an inquest into the death of a juvenile in prison custody. The jury concluded that his death had been caused by systemic neglect on the part of the prison service, the youth justice board and the London Borough of Lambeth.
Re Allen, dec’d 2002
A verdict of accident contributed to by neglect in respect of the death of a young woman who was in the custody of Securicor at Barkingside Magistrates Court and was found hanging from an open cell hatch.
Sey v Metropolitan Police Commissioner 2001
£45,000 settlement achieved in a claim for damages arising out of the restraint related unlawful killing of Ibrahima Sey in the custody of the Metropolitan Police.
Palmer v Home Office 2001
£50,000 settlement achieved in claim for damages arising out of the restraint related death of Dennis Stevens in the custody of HMP Dartmoor.
Re Alton Manning, dec’d 2001
Formal complaint alleging gross neglect of duty in respect of the conduct of an investigation by West Mercia Police into the restraint related unlawful killing of Alton Manning in custody (see below) – investigation of complaint by Staffordshire Police under supervision of PCA resulted in findings including serious systemic failures on the part of West Mercia Police in the approach to and handling of the case, and eventually to the ACPO protocol of January 2006 for police investigation of prison, probation and immigration related deaths in custody.
Re Henderson 2001
Accident contributed to by neglect in the case of this young man who hanged himself in HMYOI Brinsford.
R v DPP ex parte Manning and Melbourne 2000
Successful challenge to refusal of the DPP to prosecute prison officers involved in respect of the restraint related unlawful killing of Alton Manning in custody – a ground breaking judgement by the LCJ anticipating the impact of the Human Rights Act 1998 and requiring reasons to be given by the CPS for decisions not to prosecute in such cases.
Re B, dec’d 2001
Open verdict at inquest into the death of a mental patient in care of Sunderland City Council Social Services & Priority Healthcare Wearside NHS Trust.
Lapite v Metropolitan Police Commissioner 1999
£15,000 settlement in claim for damages arising out of unlawful killing of Oluwashijibomi Lapite (see below).
Re Alton Manning, dec’d 1998
Inquest verdict of unlawful killing in respect of restraint related death in custody of HMP Blakenhurst – highlighted yet again the dangers inherent in the use of neck holds.
R v HM Coroner for Inner North London ex parte Humphreys 1998
Settled pre leave application with the effect of reversing the Coroner’s decision not to call expert evidence or sit with a jury in case involving over-prescribing by GP.
R v Kidderminster Coroner and Alberta Cameron ex parte UKDS and Home Office 1998
Successful resistance to challenge mounted by the private company (UKDS) running HMP Blakenhurst and the Home Office against decision of Coroner to leave unlawful killing as a verdict for the inquest jury to consider in connection with the restraint related death of Alton Manning in custody of HMP Blakenhurst.
Re Sebastian dec’d 1998
Open verdict in respect of the self inflicted death of a paranoid schizophrenic in HMP Belmarsh. The inquest dealt with issues of the care given to him whilst in prison custody.
Re O’Dwyer dec’d 1998
Open verdict in respect of the self inflicted death of a life sentence prisoner at HMP Bullwood Hall. The inquest dealt with issues of the care given to him whilst in prison custody.
R v DPP ex parte Ilett and others 1998
Successfully intervened as an interested party to oppose an application by police officers not to stand trial for the manslaughter of Richard O’Brien in custody
R v DPP and PCA ex parte Lapite 1997
R v DPP ex parte O’Brien
R v DPP ex parte Treadaway
Successful challenges to the refusal of DPP and PCA to prosecute or discipline police officers involved in unlawful killings of Oluwashijibomi Lapite and Richard O’Brien, and the torture of Derek Treadaway – the first instance of a successful challenge to the exercise of the DPP’s prosecutorial discretion, resulting in a judicial inquiry and, at least in part, the decision of the then DPP to resign.
Re John Leo O’Reilly, dec’d 1997
Open verdict. Further to the Divisional Court’s ruling, the second inquest involved a more thorough examination of the police officers conduct leading in due course to disciplinary findings against four police officers and recommendations concerning the care of detainees in police custody.
Re Ibrahima Sey, dec’d 1997
Inquest verdict of unlawful killing concerning a restraint related death in the custody of the Metropolitan Police – highlighted the dangers of positional/restraint asphyxia and CS spray.
Re Dennis Stevens, dec’d 1997
Inquest verdict of death by misadventure concerning a restraint related death in custody of HMP Dartmoor which highlighted the dangers of positional/restraint asphyxia and the use of body belts.
R v HM Coroner for Exeter & East Devon ex parte Palmer, CA 1997
Representation of the family in challenge to the decision of the Coroner not to leave unlawful killing as a verdict for the inquest jury to consider in connection with the restraint related death of Dennis Stevens in custody of HMP Dartmoor – leading authority in judgment by the LCJ on the approach to be adopted by a Coroner in deciding what verdicts are to be left to an inquest jury at the conclusion of the evidence.
Re Barry, dec’d 1997
Suicide verdict in respect of a self inflicted death of a young offender in Feltham YOI. The jury in completing the inquisition highlighted all the concerns of the family regarding the deceased’s treatment in Feltham.
Re Severin, dec’d 1997
Open verdict in respect of the restraint related death of a paranoid schizophrenic in HMP Belmarsh. The inquest dealt with issues of the care given to him whilst in prison custody.
Re Holmes, dec’d 1997
Verdict of misadventure in respect of the self inflicted death of a very vulnerable young man in HMP Belmarsh. The inquest dealt with issues of the care given to him whilst in prison custody.
R v Her Majesty’s Coroner for Coventry ex parte O’Reilly 1996
Quashing of original inquest and order for a fresh inquest. A rare decision of the Divisional Court overturning an inquest on the grounds that there had been insufficient inquiry with helpful remarks as to the importance of disclosing relevant documentation to bereaved families.
Re Oluwashijibomi Lapite, dec’d 1996
Inquest verdict of unlawful killing concerning a restraint related death in the custody of the Metropolitan Police – highlighted yet again the dangers inherent in the use of neck holds.
Re Richard O’Brien, dec’d 1995
Inquest verdict of unlawful killing concerning a restraint related death in the custody of the Metropolitan Police which highlighted the dangers inherent in the use of prone restraint.
Pryce v Cleveland Police 1995
£68,000 settlement and admission of liability in respect of a claim for damages arising out of restraint related unlawful killing of Oliver Pryce in custody of Cleveland Police in a restraint related incident.
Rose v Metropolitan Police Commissioner 1990
£130,000 settlement in a claim for damages arising out of restraint related unlawful killing of Winston Rose in the custody of the Metropolitan Police in a restraint related incident.
Re Germaine Alexander, dec’d 1990
Inquest verdict of death by natural causes aggravated by lack of care in respect of a restraint related death in custody of HMP Brixton – highlighted the dangers of positional/restraint asphyxia which was not then a phenomenon understood in medical science.
R v HM Coroner for Wolverhampton ex parte McCurbin  1 WLR 719 at 728A per Woolf LJ
Representation of the family in challenge to inquest verdict of death by misadventure in respect of a restraint related death of Clinton McCurbin – leading authority on the standard of proof necessary for an unlawful killing verdict.
Re Clinton McCurbin, dec’d 1988
Inquest verdict of death by misadventure in respect of a restraint related death in the custody of West Midlands Police – highlighted the dangers inherent in the use of neck holds.