Latest on Article 2 inquests: ordinary clinical negligence will not automatically result in a human rights inquest

Inquests following the death of a detained patient will often trigger an Article 2 inquest. This will mean lengthy and difficult court proceedings.

In the past, if a deceased patient's freedom was restricted under the Mental Health Act 1983 or Mental Capacity Act 2005, health and care organisations may be assumed to have become responsible for their care. Human rights inquests will follow with full enquiry into the circumstances surrounding the death. A jury is likely.

The recent judicial review in the case of Maguire confirms earlier guidance making it clear that, where a health and care organisation operates high professional standards but an error of judgment or individual negligence occurred around the time of a patient’s death, this alone is not enough to warrant an Article 2 inquest.

There must now be a “reason to believe that there may have been a breach which is a “systemic failure”, in contrast to an “ordinary” case of medical negligence.”

In the case of Maguire, the patient Jackie, died following a perforated ulcer. She was subject to a deprivation of liberty order and accommodated in a care home.

Jackie had Down’s Syndrome and had asked to be taken to the GP with a sore throat, vomiting, diarrhoea and a temperature. This was not acted upon until after Jackie collapsed at the home, after which poor and unsuccessful efforts were made to obtain medical attention for her. A couple of days later, Jackie collapsed again overnight. Jackie was not found until the morning, at which point she was taken to hospital by ambulance. Jackie died later that same evening. 

The coroner at Jackie’s inquest concluded that, despite these failures, the health and care organisation involved was not at fault of a systemic failure in the provision of her care. The faults were due to individual actions and the state should not be called to account under Article 2 of the European Convention on Human Rights. The judicial review proceedings into the coroner’s original decision confirm this was, indeed, the correct decision to take, in law.


If your organisation is facing the prospect of an Article 2 inquest, make sure there is careful consideration of whether there really is reason to believe there was a systemic failure to provide care. If not, it may not be necessary for the coroner to conduct an Article 2 inquest.

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