判决理由
Where Article 2 ECHR is engaged (deaths in state custody or involving state responsibility), an inquest must examine not just how (by what means) the deceased died, but in what circumstances, including the broader question of systemic failings.
事实
A prisoner committed suicide in prison. The coroner directed the jury that they could only investigate 'how' (by what means) the death occurred, not the broader circumstances.
判决摘要
The House of Lords held that in Article 2 cases, 'how' must be interpreted as 'by what means and in what circumstances'. The jury could return a narrative verdict addressing systemic failings.
关键引述
"The word 'how' in section 11(5)(b)(ii) must be interpreted as meaning not simply 'by what means' but 'by what means and in what circumstances'."
— Lord Bingham
后续处理
Established the 'Middleton inquest' for Article 2 cases.