Where the coroner had failed to leave certain issues to the jury, a new inquest was ordered to determine whether systemic neglect was a contributory cause of the deceased prisoner's death.Appeal by the claimant ('C') from an order by Moses J on 11 February 2003 dismissing her application for judicial review of a coroner's inquest held into the death of her son ('D') in prison. D was dependent on heroin and was seen by a doctor on his admission to prison where he was prescribed detoxification drug treatment. He did not receive this treatment after the initial dose and then became extremely ill. D was seen several times by the prison nurse over a period of a few days but was not seen by a doctor and subsequently died four days after his admission to prison. An inquest took place at which the jury reached a verdict of accidental death. C sought judicial review of the inquest on the basis that the coroner: (i) failed properly to direct the jury as to the meaning of neglect; (ii) in particular he wrongly emphasised the rarity of a verdict that neglect had contributed to the cause of death; (iii) failed to admit the evidence of an expert doctor which reflected the doctor's views as to the quality of care afforded to D; (iv) failed to explain that there were circumstances in which the nurse's failure to seek assistance could amount to neglect; and (v) failed adequately to leave to the jury any issues relating to a systemic failure in the prison's arrangements for caring for a prisoner who needed medication for drug withdrawal. Moses J found that the coroner's summing up to the jury was defective but that it was not necessary or desirable in the interests of justice to quash the verdict of the jury and order a fresh inquest. He found that the coroner had conducted a very full inquiry and made recommendations to the prison governor accordingly. Therefore, the judge held that there was nothing to be gained from another inquest.HELD: (1) The law was in an unsettled state and the English coronial system was currently an inadequate vehicle for the procedural obligations imposed by Art.2 of the European Convention on Human Rights. (2) It followed from R (On the application of Imtiaz Amin) v Secretary of State for the Home Department (2003) UKHL 51 that: (a) there had to be a full and effective inquiry into the death at a coroner's inquest if this was realistically the only occasion on which the state could perform its procedural duty; (b) it was open to the jury to return a verdict incorporating a finding of neglect in a broader range of circumstances than was envisaged in R v North Humberside and Scunthorpe Coroner ex p Jamieson (1994) 3 WLR 82 if the case related to systemic neglect; and (c) a letter written by a coroner pursuant to r.43 Coroners Rules 1984/552 was not an adequate substitute, for Art.2 purposes, for a verdict by the jury in cases where a verdict of neglect was available on the evidence. (3) Moses J's criticisms of the coroner's summing up were correct. It was understandable that the judge decided against a further inquest as he was not able to consider the judgment of Amin (Supra) or McGlinchey v UK (2003)(Unreported, ECHR, 2003). (4) As the law now stood the judgment could not stand. The inquest alone had the burden of fulfilling the Convention obligations and an inquest which did not canvas the issue of systemic neglect properly or at all did not perform that function. The inquisition would be quashed and a new inquest would be ordered to determine whether systemic neglect was a contributory cause of D's death.Appeal allowed.
 EWCA (Civ) 1739