Case Summary: R (Maguire) v HM Senior Coroner for Blackpool Fylde [2020] EWCA Civ 738

• Inquests
• Article 2 inquests
• Medical negligence
• Deprivation of Liberty Safeguards

Practitioners, healthcare providers and commissioners should be mindful that:

• The State’s duties under Article 2 of the European Convention on Human Rights (“ECHR”) are not triggered automatically if a vulnerable person, who is subject to a DoLS standard authorisation, dies in a care home following possible failures by medical professionals.
• The scope of the State’s operational duty is a key factor in determining whether Article 2 is engaged.

The Court of Appeal considered the decision of the Divisional Court who dismissed a claim for judicial review. The judicial review sought to reverse the Coroner’s decision that the inquest into Jackie Maguire’s death was not an Article 2 inquest and that neglect was not open to the jury (the latter argument was not pursued in the appeal).  

There were three grounds to the appeal:

Ground 1: The Divisional Court erred in concluding that the procedural obligation under Article 2 ECHR did not apply. By parity of reasoning with Rabone v Pennine Care NHS Foundation Trust [2012] UKSC 2 (‘Rabone’), the circumstances of Jackie’s care dictated that the procedural obligation applied. It was not a medical case of the sort considered in R (Parkinson) v Kent Senior Coroner [2018] 4 WLR 106 (‘Parkinson’).

Ground 2: If Parkinson applied, the Divisional Court was wrong to conclude that the failure to have in place a system for admitting Jackie to hospital on the evening of 21 February 2017 did not amount to a systemic failure.

Ground 3: The Divisional Court erred in failing to take account of the wider context of premature deaths of people with learning disabilities (such information being known to the Senior Coroner at the time even if not in evidence before him) but in any event being relevant to the application of Article 2 in these circumstances.

None of the grounds succeeded and the Court of Appeal dismissed the appeal.

Jackie Maguire was a 52-year old woman with Down’s Syndrome, learning disabilities, behavioural difficulties and some physical limitations. She lived in a residential care home and was subject to a standard authorisation pursuant to the Deprivation of Liberty Safeguards.

On 16 February 2017, Jackie was not eating well and was complaining of a sore throat. On 20 February 2017, she vomited and asked to see a doctor but no action was taken by the care home staff. On 21 February 2017, Jackie had a fit and staff contacted the GP and NHS 111.  During a phone conversation, the GP concluded that Jackie had viral gastroenteritis and urinary tract infection and issued a prescription. That evening, Jackie collapsed and an ambulance was called but they were not made aware that Jackie had Down’s syndrome. The paramedics wanted to take Jackie to hospital but she refused and the crew thought that manhandling her might cause injury. The paramedics discussed Jackie’s case with the out of hours GP and given that Jackie did not look seriously unwell, it was agreed that she would remain at home and would be monitored. In the morning of 22 February 2017, Jackie collapsed and she was taken to hospital. She died that evening following a cardiac arrest. The cause of death was perforated gastric ulcer and pneumonia.

At the Pre-Inquest Review Hearing, the Coroner decided that Article 2 was engaged. At the conclusion of the evidence, however, the Coroner reconsidered the position and decided that Article 2 was not engaged as the allegations against the healthcare providers fell under medical negligence, which do not trigger the State’s procedural obligations under Article 2, further to Parkinson.  

A judicial review into the Coroner’s decision that Article 2 was not engaged and that neglect was not open to the jury was unsuccessful, so an application was made to the Court of Appeal on the following grounds:

Ground 1: The Divisional Court erred in concluding that the procedural obligation under Article 2 ECHR did not apply. By parity of reasoning with Rabone, the circumstances of Jackie’s care dictated that the procedural obligation applied. It was not a medical case of the sort considered in Parkinson.

Ground 2: If Parkinson applied, the Divisional Court was wrong to conclude that the failure to have in place a system for admitting Jackie to hospital on the evening of 21 February 2017 did not amount to a systemic failure.

Ground 3: The Divisional Court erred in failing to take account of the wider context of premature deaths of people with learning disabilities (such information being known to the Senior Coroner at the time even if not in evidence before him) but in any event being relevant to the application of Article 2 in these circumstances.

The Court of Appeal dismissed the appeal for the following reasons:

Ground 1:

The Court of Appeal decided that there is no case law by the European Court of Human Rights which supports that for all purposes an operational duty is owed to people in a vulnerable position in care homes, which would then trigger the procedural obligation when a death follows alleged failures or inadequate interventions by medical professionals. It is necessary to consider the scope of any operational duty.

The Court of Appeal held that Jackie’s circumstances were not analogous with a psychiatric patient, as she did not receive medical treatment. She was looked after by carers because she was unable to look after herself. If she needed medical treatment it was sought, in the usual way, from the NHS. On the evening of 21 February 2017, the GP and paramedics did not think that there was a risk to Jackie’s life. 

Therefore, there was no basis for believing that Jackie’s death was the result of a breach of the operational duty to protect life. As a result, the procedural obligation did not arise.

Ground 2:

The Court of Appeal rejected the argument that Jackie’s life was knowingly put in danger by a denial of life-saving emergency treatment. The collective judgement of the professionals was that she was not in danger on the evening of 21 February 2017. The Court did not accept that it was a case which raised systemic or structural dysfunction in medical services. There was no evidence that there was a widespread difficulty in taking individuals with learning disabilities to hospital when it is in their interests to do so.

The criticism that a protocol or guidance should have been in place to achieve Jackie’s transfer to hospital was rejected, as this was too remote from the type of systemic regulatory failing which would trigger the State’s operational duty. 

Ground 3:

The Court of Appeal held that research into the complex issues as to why people with learning disabilities have reduced life expectancy is valuable, but it did not provide additional weight to the argument that the operational duty was owed to Jackie.

• The State’s duties under Article 2 ECHR are not triggered automatically if a vulnerable person, who is subject to a DoLS standard authorisation, dies in a care home following possible failures by medical professionals.

• The scope of the State’s operational duty is a key factor in determining whether Article 2 is engaged. In this case, there was no basis to believe that the death was a result of a breach of the operational duty to protect life, and thus the procedural obligation was not engaged.