Chambers v HM Coroner for Preston and West Lancashire & Ors

Judgment

Lord Justice Bean :

This is the judgment of the court to which we have both contributed.

On 26 th January 2004 Stephen Chambers was found hanging in his cell at HMP Preston. On 14 th May 2007 an inquest was held before HM Coroner, Dr James Adeley and a jury. The jury returned, and the Coroner recorded, a verdict that Mr Chambers died:-

“between 09:30am and 10:12am on 26 th January 2004 at HMP Preston in Cell C2-31; and that this was

from hanging which caused his death. Among the contributing factors were his family problems and bullying. There is not enough evidence to suggest that the prison were aware of this bullying.”

Since the claimant was less than three years old when her father died we may safely infer that it is her mother and litigation friend Mrs Deborah Chambers who is the real driving force behind this litigation. Mrs Chambers was neither present nor represented at the inquest. Her solicitors had asked to be notified of the date of the inquest but because of an oversight they were not so notified. Mrs Chambers is dissatisfied with the verdict reached at the 2007 inquest on the grounds both of an irregularity in the proceedings (namely the failure to notify her or her solicitors) that it was to take place and insufficiency of inquiry, to which we shall return in detail later in this judgment. She applied for the fiat of the Attorney General under Section 13 of the Coroners Act 1988 authorising an application to the High Court for an order quashing the original inquest and directing the holding of a fresh one. The then Solicitor General, Oliver Heald QC MP, gave such authorisation on 24 th February 2014.

Mr Chambers had been in prison on a number of occasions, including from January 2001 to early 2003. For a substantial part of that time there was an open F2052 SH (self harm at risk) form in respect of him. During his time in custody in the year 2001 he attempted to hang himself on five occasions.

In July 2003 he committed a further offence and on 9 September 2003 was sentenced to 11 months imprisonment. On arrival that day at HMP Preston he was again subject to an open form F2052. He informed medical officers that his mother had recently died. This was untrue: his mother Pauline, the second Interested Party, was and is still alive. He expressed feelings of depression because of his mother’s alleged death but also because he was going through divorce proceedings, as well as his claimed innocence of the charge. He told staff that