Maguire, R (on the application of) v His Majesty’s Senior Coroner for Blackpool & Fylde & Anor [2023] UKSC 20

Jackie Maguire, a vulnerable adult with Downs Syndrome living in a care home under deprivation of liberty safeguards, died from a perforated gastric ulcer after not being taken to hospital despite symptoms. Her mother challenged the coroner's decision not to require an expanded verdict under Article 2 ECHR. The Supreme Court dismissed the appeal, finding no arguable breach of systems or operational duties.

Facts

Jacqueline Maguire (‘Jackie’), aged 52, had Downs Syndrome, learning disabilities, and physical limitations. She resided at a care home since 1993 and was subject to a Deprivation of Liberty Safeguards authorisation under the Mental Capacity Act 2005, as she lacked capacity to make decisions about her care. On 21 February 2017, Jackie became seriously unwell with vomiting, stomach pain, and collapse episodes. Care home staff contacted NHS 111 and her GP, and an ambulance attended. The paramedics and an out-of-hours GP concluded it was not necessary to take Jackie to hospital, partly because she resisted going and they assessed she was not displaying ‘red flag’ signs. Jackie remained at the care home overnight. By the next morning her condition had deteriorated dramatically. She was then taken to hospital but died that evening from pneumonia and a perforated gastric ulcer with peritonitis.

The Inquest

The coroner conducted a thorough inquest with a jury. At the close of evidence, he ruled that Article 2 ECHR did not require an expanded verdict (a ‘Middleton-style’ verdict) because there was no arguable breach of the substantive positive obligations under Article 2. The jury returned a short form verdict that Jackie died of natural causes.

Issues

The central issue was whether the coroner erred in law by not directing the jury to return an expanded verdict under section 5(2) of the Coroners and Justice Act 2009, which requires consideration of the circumstances of death where necessary to avoid a breach of Convention rights. This depended on whether the enhanced procedural obligation under Article 2 ECHR applied, which in turn required determining whether there was an arguable breach of either:

• The ‘systems duty’ (obligation to have appropriate regulatory frameworks and systems in place to protect life); or
• The ‘operational duty’ (obligation to take preventive operational measures to protect a specific individual from a real and immediate risk to life of which authorities knew or ought to have known).

Judgment

The Systems Duty

Lord Sales (with whom Lord Reed, Lord Lloyd-Jones, and Lady Rose agreed) emphasised that the systems duty operates at a high level and is relatively easily satisfied. Referring to the Grand Chamber’s guidance in Lopes de Sousa Fernandes v Portugal, he stated:

where a contracting state has made adequate provision for securing high professional standards among health professionals and the protection of the lives of patients, matters such as an error of judgment on the part of a health professional or negligent coordination among health professionals in the treatment of a particular patient are not sufficient of themselves to call a contracting state to account from the standpoint of its positive obligations under article 2

The Court found that proper regulatory frameworks were in place via the Care Quality Commission for care homes and relevant healthcare regulators for medical services. Individual lapses in applying systems do not equate to systemic failures:

individual lapses in putting a proper system into effect are not to be confused with a deficiency in the system itself

The Operational Duty

Regarding the operational duty, the Court held that the question is whether authorities knew or ought to have known of a real and immediate risk to life. Lord Sales explained the targeted nature of this duty:

the article 2 operational duty is not one to take steps in the abstract, but rather to take steps to avert a specific risk to life; until the specific risk to life has been identified, it is impossible to answer the duty question

Applying this to the care home, the staff had sought medical advice and called an ambulance when Jackie became unwell. They were entitled to rely on the judgment of medical professionals who did not consider her life was in danger. As for the healthcare providers, none were on notice that Jackie’s life was in danger on 21 February 2017; the medical assessment was that she did not need to be taken to hospital that evening.

Vulnerability and Deprivation of Liberty

The Court rejected the argument that Jackie’s vulnerability and deprivation of liberty automatically triggered the enhanced procedural obligation. The operational duty must be targeted at a specific known risk:

When an individual is placed in a care home, a nursing home or a hospital, the state’s operational duty in the targeted sense derived from Osman, para 116, does not involve an assumption of responsibility extending to taking responsibility for all aspects of their physical health

Implications

This judgment provides important clarification on the scope of Article 2 ECHR duties in care settings. It confirms that:

• The mere fact that a vulnerable person is subject to deprivation of liberty does not automatically engage the enhanced procedural obligation under Article 2
• The systems duty requires adequate regulatory frameworks but does not make the state liable for individual errors within those frameworks
• The operational duty is targeted at specific known risks and does not make the state a guarantor of all aspects of healthcare for detained vulnerable persons
• In cases of alleged medical negligence, the redress procedural obligation (availability of civil claims) rather than the enhanced procedural obligation will typically apply

The judgment maintains the distinction established in Fernandes between cases of medical negligence (where civil remedies suffice) and exceptional cases of denial of healthcare or systemic dysfunction.

Verdict: Appeal dismissed. The Supreme Court held that the coroner did not err in law in deciding that an expanded verdict was not required. There was no arguable breach of either the systems duty or the operational duty under Article 2 ECHR on the part of the care home or healthcare providers, and therefore the enhanced procedural obligation did not apply.

Source: Maguire, R (on the application of) v His Majesty's Senior Coroner for Blackpool & Fylde & Anor [2023] UKSC 20