Gary Parkin, R (on the application of) v His Majesty’s Assistant Coroner for Inner London (East)
[2024] EWHC 744 (Admin)
R (on the application of Maguire) v His Majesty’s Senior Coroner for Blackpool & Fylde and another
21 June 2023
[2023] UKSC 20
Supreme Court
A woman with disabilities died after delays in getting medical help. Her family sued, saying the system failed her. The court said individuals made mistakes, not the whole system, so there was no grounds for a new inquest.
Key Facts
- •Jacqueline Maguire (Jackie), 52, died in hospital on February 22, 2017, from pneumonia, a perforated gastric ulcer, peritonitis.
- •Jackie had Down's Syndrome, learning disabilities, and behavioral difficulties.
- •She resided in a care home, her placement funded by Blackpool City Council, and was subject to a Deprivation of Liberty Safeguards (DoLS) order.
- •On February 21, 2017, Jackie exhibited concerning symptoms (vomiting, abdominal pain, breathing difficulties).
- •Calls were made to her GP and NHS 111, but there were communication failures and delays in receiving medical attention.
- •Paramedics visited but did not take her to the hospital due to her refusal and concerns about forced intervention.
- •Jackie's condition deteriorated overnight, and she was taken to the hospital on February 22, 2017, but died later that day.
- •The inquest investigated potential breaches of Article 2 ECHR (right to life).
Legal Principles
Article 2 ECHR imposes substantive (systems and operational duties) and procedural obligations on the state to protect life.
Human Rights Act 1998, European Convention on Human Rights
The operational duty arises when the state knows or ought to know of a real and immediate risk to a specific person's life.
Osman v United Kingdom, Rabone v Pennine Care NHS Trust
The systems duty requires the state to have appropriate legal and administrative systems to protect life.
Various case law
Procedural obligations under Article 2 are graduated depending on the circumstances, including basic, enhanced, and redress obligations.
Middleton v West Somerset Coroner, Morahan v West London Assistant Coroner
In medical negligence cases, the state's obligation usually involves providing access to civil remedies, not necessarily an expanded inquest verdict.
Powell v United Kingdom, Calvelli and Ciglio v Italy, Fernandes v Portugal
Section 5(2) of the Coroners and Justice Act 2009 allows for an expanded inquest verdict to avoid breaching Convention rights.
Coroners and Justice Act 2009
The Ullah principle requires domestic courts to have confidence that the Strasbourg Court would find a violation.
R (Ullah) v Special Adjudicator
Outcomes
Appeal dismissed.
The Court found no arguable breach of the systems or operational duties under Article 2, either by the care home or healthcare providers. The failures identified were primarily due to individual actions or communication issues, not systemic flaws.
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