Information Note on the Court’s case-law 40
March 2002
Paul and Audrey Edwards v. the United Kingdom - 46477/99
Judgment 14.3.2002 [Section III]
Article 2
Article 2-1
Life
Killing of detainee by mentally ill cell-mate and effective of subsequent investigation: violation
Facts: The applicant’s son, C., was arrested in November 1994 after making inappropriate suggestions to young women in the street. His behaviour led the police to suspect that he might be mentally ill. He was assessed at the police station by an approved social worker, who spoke to a psychiatrist by telephone. They agreed that C. was fit to be detained. The following day, C. was brought before the Magistrates’ Court, where he had to be restrained after confronting a female prison officer. He was placed in a cell, where he continually banged on the door and shouted obscenities about women. The court, which considered that it did not have power to order C.’s remand to hospital, remanded him in custody. At the prison, he was screened by a member of the health care staff, who knew nothing of the concerns about his mental health and saw no reason to admit him to the Health Care Centre. No medical officer was present in the prison at the time. C. was initially placed in a cell on his own but subsequently another detainee, R.L., was placed in the same cell. R.L., who had a history of mental illness, had been arrested for assault. A police surgeon had certified that he was not fit to be detained. However, he had then been assessed by a psychiatric registrar, who had spoken to a consultant by telephone. The latter had decided that R.L. was fit to be detained and the police surgeon at the police station to which he was transferred had been of the same view. They had attributed his bizarre behaviour to alcohol and drug abuse. Although the police had considered that R.L. was mentally ill, the relevant form had not been completed. On his arrival at the prison, R.L. had been screened by the same person who had screened C. That person had not been aware of R.L.’s previous convictions or admittance to hospital and had seen no reason to admit him to the Health Care Centre. R.L. was put in C.’s cell due to shortage of space. During the night, a prison officer, on going to investigate continuous banging on a cell door, saw that the green emergency light outside the cell, operated by a call button in the cell, was on, although the accompanying buzzer was not sounding. Prison officers entered the cell and found that C. had been stamped and kicked to death. R.L., who was suffering from paranoid schizophrenia, pleaded guilty to manslaughter by reason of diminished responsibility and was detained in a special hospital. An inquest which had been opened and adjourned pending the criminal proceedings was closed as there was no obligation to continue in those circumstances. A private, non-statutory inquiry was commissioned by the three agencies with statutory responsibilities towards C. (the prison, local government and health authorities). The inquiry, which sat in private, heard evidence on 56 days over a period of 10 months from May 1996. It had no power to compel witnesses and two prison officers declined to give evidence. The inquiry report, issued in June 1998, concluded that ideally C. and R.L. should not have been in prison and in practice should not have been sharing the cell and found that there had been “a systemic collapse of the protective mechanisms”. It identified a series of shortcomings, including poor record-keeping, inadequate communication and limited inter-agency co-operation. The applicants were advised by their lawyers that no civil remedies were available to them and the Crown Prosecution Service maintained its earlier decision that there was insufficient evidence to proceed with criminal charges.
Law: Article 2 – (a) As a prisoner, C. fell under the responsibility of the authorities who had an obligation, under both domestic law and the Convention, to protect his life. The first question was whether the authorities knew or ought to have known of the existence of a real and immediate risk to his life, and in that respect the essential issue was whether the prison authorities knew or ought to have known of R.L.’s extreme dangerousness when the decision to place him in the same cell as C. was taken. R.L.’s doctors knew he was mentally ill and he had a history of violence, and the initial assessment by a police surgeon was that he was not fit to be detained. This was, however, overruled by a registrar who did not consult R.L.’s notes. The health worker at the prison knew that R.L. had been difficult but was not made aware of his prison record or his previous committal to hospital and the police, prosecution and court did not pass on any detailed information relating to his conduct and his known history of mental disturbance. Information was, therefore, available which identified R.L. as suffering from a mental illness and with a record of violence and this, in combination with his bizarre and violent behaviour, demonstrated that he was a real and serious risk to others. As regards the measures which the authorities might reasonably have been expected to take to avoid that risk, the information concerning R.L.’s medical history and perceived dangerousness was not brought to the attention of the prison authorities, and in particular those responsible for deciding whether to place him in the Health Care Centre. There was a series of shortcomings in the transmission of information (the failure of the registrar to consult R.L.’s notes, the failure of the police to fill in the relevant form, the failure of the police, prosecution and court to inform the prison authorities of R.L.’s suspected dangerousness and instability). These defects were combined with the brief and cursory nature of the examination carried out by the screening health worker, acting in the absence of a doctor to whom recourse could be made in the case of difficulty or doubt. There were in addition numerous failings in the way in which C. was treated from his arrest to allocation to a shared cell. However, although it would obviously have been desirable for him to be detained in a hospital or the Health Care Centre of the prison, his life was placed at risk by the placement of a dangerously unstable prisoner in his cell and it was the shortcomings in that regard which were most relevant to the issues in the case. In conclusion, the failure of the agencies involved to pass on information about R.L. to the prison authorities and the inadequate nature of the screening process on R.L.’s arrival in prison disclosed a breach of the State’s obligation to protect C.’s life.
Conclusion: violation (unanimously).
(b) A procedural obligation arose to investigate the circumstances of C.’s death. He was a prisoner under the care and responsibility of the authorities when he died from acts of violence of another prisoner and in that situation it was irrelevant whether State agents were involved by acts or omissions in the events leading to his death. Civil proceedings, assuming they were available, lay at the initiative of the victim’s relatives and would not satisfy the State’s obligation in this regard. Since no inquest was held and the criminal proceedings did not involve a trial, the question was whether the inquiry provided an effective investigative procedure. The inquiry heard a large number of witnesses and reviewed the circumstances of C.’s death in detail and its report was a meticulous document which could be relied on to assess the facts. Moreover, there was no lack of independence and in the circumstances the authorities could be regarded as having acted with sufficient promptness and proceeded with reasonable expedition. However, the inquiry’s lack of power to compel witnesses meant that potentially significant evidence was not available and this had to be regarded as diminishing the effectiveness of the inquiry. Furthermore, the public interest attaching to the issues thrown up by the case was such as to call for the widest exposure possible and no reason had been put forward for holding the inquiry in private. In addition, the applicants were only able to attend the inquiry when giving evidence, they were not represented and were unable to put any questions to witnesses, and they had to wait until the publication of the report to discover the substance of the evidence. Given their close and personal concern with the subject-matter of the inquiry, they were not involved in the procedure to the extent necessary to safeguard their interests. There had consequently been a violation of the procedural obligation under Article 2.
Conclusion: violation (unanimously).
Articles 6 and 8 – The Court concluded unanimously that no separate issue arose under these provisions.
Article 13 – While a civil action might have furnished a fact-finding forum with the power to attribute responsibility for C.’s death, it was not apparent that non-pecuniary damages would have been recoverable or that legal aid would have been available to pursue civil claims. Consequently, this avenue of redress was not, in the circumstances of the case, of practical use. Similarly, while it was not inconceivable that a case might be brought under the Human Rights Act 1998, this would relate only to any continuing breach of the procedural obligation under Article 2 of the Convention after 2 October 2000 and would not provide damages related to C.’s death, which preceded the entry into force of the Act. The Government had not referred to any other procedure whereby the liability of the authorities could be established in an independent, public and effective manner, and the Court had already found that the inquiry failed for reasons of procedural defects to comply with the procedural obligation imposed by Article 2 and did not provide any possibility of obtaining damages. Notwithstanding the aggregate of remedies referred to by the Government, the applicants did not have available to them an appropriate means of obtaining a determination of their allegations that the authorities had failed to protect their son’s right to life and the possibility of obtaining an enforceable award of compensation for the damage suffered. This is an essential element of a remedy under Article 13 for a bereaved parent.
Conclusion: violation (unanimously).
Article 41: The Court made awards in respect of non-pecuniary damage and in respect of costs and expenses.
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This summary by the Registry does not bind the Court.
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