On 21 June 2023, Lord Reed, Lord Lloyd-Jones, Lord Sales, Lord Stephens and Lady Rose of the Supreme Court dismissed the appeal of Muriel Maguire in the case of Muriel Maguire v HM Senior Coroner for Blackpool and Fylde.
Muriel Maguire’s daughter, Jacqueline Maguire, known as Jackie, was disabled, had Down’s syndrome, and lived in a residential care home under a Deprivation of Liberty Safeguards (DoLS) Order, when she died.
The Supreme Court determined that Jackie’s death did not engage the state’s obligation to protect life under Article 2 (right to life) of the European Convention on Human Rights (ECHR), thereby requiring the inquest jury to make findings regarding the circumstances in which she died.
Comment from Mrs Maguire
I am dismayed and distraught at the Supreme Court’s decision to dismiss my appeal. The circumstances of my daughter Jackie’s death were truly dreadful. For many days, Jackie had had diarrhoea, a sore throat and was off her food, but her care staff at United Response did not do anything. Then on 20 February she was vomiting and had a temperature, but the staff ignored her request for a doctor – so she got worse. On the morning of 21 February, she had problems breathing but the staff again did not act on her request for a doctor. She then collapsed in the early afternoon, but the staff contacted the GP surgery rather than 999, which suggested they contacted 111. The 111 service was contacted and told that Jackie had severe stomach pain, had had a fit, and was vomiting blood, but instead of immediately sending an ambulance they said to contact the surgery and say a doctor should come to see Jackie within two hours. The surgery asked if Jackie could be brought to them. They were told Jackie was too poorly to come. A GP from the surgery did not visit Jackie but telephoned at 5.00pm instead and misdiagnosed her with a urinary tract infection (UTI) and wrote a prescription for an antibiotic. Jackie continued to get worse. She was so ill she tried to go to bed very early at 7.00pm but kept collapsing on the staircase. Staff again called the 111 service rather than 999. An hour later an ambulance attended but the paramedics did not take Jackie to hospital because they were afraid to manhandle her. They telephoned an out of hours GP who advised it would be a ‘bit daft’ to call an ambulance out at that time of night. So the paramedics left without Jackie who remained in the care home overnight in the care of one young staff member with no medical qualifications. By the morning of 22 February Jackie was desperately ill. At 8.00am she was unconscious on the bathroom floor when the care home manager arrived after several days off work and dialled 999. An ambulance attended and Jackie arrived at Victoria Hospital at 9.30am where doctors mistakenly thought her septic shock resulted from a UTI (she did not have a UTI), and failed to diagnose that Jackie had a perforated stomach ulcer and peritonitis, and pneumonia. She also never received the recognised treatments for septic shock. There were no beds for her elsewhere so Jackie had to stay in A&E all day, where at 6.30pm a nurse found her in cardiac arrest and she could not be resuscitated. What she went through in the last 48 hours of her life was unimaginable, appalling. She was so badly let down by so many people with responsibility for her care. It’s still so painful to bear even now six years after her death. I think it always will be.
It was good to have the Equality and Human Rights Commission and Mind, supporting my appeal to the Supreme Court. I saw the Commission’s article today and it said people like Jackie, who are detained where they live and deprived of their liberty and lack capacity, should be owed the same level of human rights protection as other vulnerable people such as those detained in mental health hospitals, prisoners, or police custody which, as they pointed out, would have allowed the jury at Jackie’s inquest to comment on the many failings of those responsible for her care and make critical findings. It was this that the Coroner forbade the jury in Jackie’s case from doing and now the Supreme Court has unfortunately decided the Coroner did not err in how he reached that decision. This means that when people like my Jackie die the way she did, what went wrong will not be identified, lessons will not be learned, people will not be held to account, and so further deaths like hers will keep happening. This is so wrong.
Jackie was such a wonderful daughter. She could communicate by uttering one or two words at a time which, together with gesturing and the strength of her personality, meant she usually could make herself understood to those who knew her well. She was very independent-minded. She was mischievous and had a wicked sense of humour. She liked nothing more than to see her brothers and sisters get told off. She was the life and soul of the care home, very popular with the staff and the other residents. She had her own sitting room but joined the other residents for meals. She loved music, Michael Jackson and Abba were big favourites. She watched TV. I was very touched by the number of condolence cards I received after her death and the sentiments expressed. To think her life ended the way it did, the pain, the suffering. She wouldn’t have known what was happening to her. She did not deserve that. Nobody does.
Jackie was my beloved daughter. No mother should have to endure the circumstances in which she died. The court’s judgment is the judgment, but not the correct one for my beloved Jackie. I, her mother of all these years, know what a dreadful ending she had whilst in ‘care’. Had she not had Down’s syndrome we wouldn’t even be talking about this now, there lies the difference.
However, the fight to get justice for Jackie is not over. I am awaiting legal advice and very much hope to take my case to the European Court of Human Rights in Strasbourg.
Background to the case
Jackie was aged 52 at the time of her death on 22 February 2017. She had Down’s syndrome, curvature of the spine, and learning difficulties. Despite these health problems, Jackie led a happy and fulfilling life. She was much loved by her mother and siblings and had a strong and independent personality. She lived in a care home run by United Response at 85 St Anne’s Road East, Lytham St. Annes, Lancashire. She had been placed there by the Lancashire County Council, Adult Safeguarding Services.
On 4 April 2016, a Deprivation of Liberty Safeguard had been signed in respect of Jackie. The social worker and psychiatrist confirmed that Jackie lacked the capacity to make decisions about her care and treatment, and about where she should live.
Circumstances leading to the death of Jacqueline Maguire
In 2016-2017, Jackie complained constantly of pains. By November 2016, there was sufficient concern to warrant a hospital appointment to investigate a possible diagnosis of cancer.
On 20 February 2017, Jackie was ill in bed and refused to get up. She did so later. She asked for a doctor but this was not arranged by support staff.
On 21 February, Jackie was again reluctant to get out of bed. She had breathing difficulties. Staff did not act on her request for a doctor. Eventually she got up and had a seizure at 2.15pm. The GP was contacted and advised calling the NHS 111 service. That service then advised calling back the GP and said a GP should attend Jackie within two hours. The GP then asked if Jackie could be brought to the surgery, but Jackie was too ill. The GP did not visit the care home but later telephoned and misdiagnosed a urinary tract infection, and provided a prescription for an antibiotic. Jackie had another seizure at 7.00pm. The NHS 111 service was again contacted and eventually paramedics attended at 8.00pm, but Jackie refused to get out of bed. The paramedics telephoned an out of hours GP but the result was that Jackie was not taken to hospital and she was allowed to stay in the care home overnight.
On 22 February at 6.30am, the support worker, discovered Jackie in her bed, incontinent. She was weeping and appeared to have a further seizure. A 999 call was made and paramedics arrived at 8.21am. Despite Jackie’s refusal to go to hospital, they recognised that she could be taken to hospital in her best interests. Light restraint was used to escort her to the A&E Department of Blackpool Teaching Hospital.
At the hospital it was noted that Jackie had had ten days of diarrhoea and vomiting over the past two days. Jackie was misdiagnosed initially with urosepsis. She had been complaining of abdominal pain. She was found to be severely dehydrated with kidney failure and profound metabolic acidosis. She was managed on fluids and antibiotics. She was left alone for some hours. She suffered a cardiac arrest at 6.31pm. Resuscitation attempts were made but she was pronounced dead at 7.40pm. The cause of death in the post-mortem report is given as a perforated gastric ulcer with peritonitis as well as pneumonia. All of these went undiagnosed at the hospital.
An inquest into Jackie’s death before HM Coroner for Blackpool and Fylde and jury took place between 20 June and 2 July 2018. Initially, it proceeded on the basis that Article 2 ECHR (right to life) was engaged, which meant the inquest had to consider how and in what circumstances Jackie died. However, at the conclusion of the evidence and prior to the coroner’s summing up to the jury, the coroner ruled that Article 2 ECHR was no longer engaged following the case of R (Parkinson) v HM Senior Coroner for Kent  EWHC 1501 (Admin). The Coroner reached this conclusion on the basis that the allegations against Jackie’s carers and health provider amounted to allegations of individual negligence, which Parkinson clarified fell outside the scope of Article 2 ECHR. As a result, the jury was only allowed to consider how Jackie came by her death, rather than how and in what circumstances she died: a wider concept. The jury concluded that Jackie died of natural causes and recorded a short narrative conclusion.
Muriel Maguire brought a judicial review on the ground that the Coroner was wrong to conclude that Article 2 did not apply in Jackie’s case, and neglect should have been left to the jury. The hearing took place before Irwin LJ, Farbey J and HHJ Lucraft KC, who was the Chief Coroner for England and Wales (2016-2020). Judgment was formally handed down by the Divisional Court on 15 May 2019. The application for judicial review was dismissed.
Muriel Maguire appealed to the Court of Appeal on the Article 2 issues. The hearing took place on 4-5 February 2020 before Rt Hon the Lord Burnett of Maldon, Lord Chief Justice of England and Wales, the Rt Hon Sir Ernest Ryder, Senior President of Tribunals and the Rt Hon Nicola Davies J, DBE. Judgment was formally handed down on 10 June 2020 dismissing the appeal.
An application for permission to appeal to the Supreme Court was lodged on 5 February 2021 after the necessary funding had been secured from the Legal Aid Agency. The grounds of appeal are summarised below:
- The court erred in following Dumpe v Latvia
- The court erred in limiting the scope of Lopes de Sousa v Portugal
- The court was wrong to determine that the conclusion in Rabone flowed naturally from the Strasbourg jurisprudence in a manner that Jackie’s case did not
Lord Reed, Lord Hamblen and Lord Stephens granted permission to appeal to the Supreme Court on 23 February 2022. The hearing took place on 22-23 November 2022 before Lord Reed, Lord Lloyd-Jones, Lord Sales, Lord Stephens and Lady Rose. Judgment was formally handed down on 21 June 2023 dismissing the appeal.
In dismissing the appeal, the Supreme Court focused on how the Coroner arrived at his decision that Article 2 was not arguably engaged rather than make its own assessment of the evidence that was before the Coroner on that issue. Taking that approach, the Supreme Court could not identify any error in the Coroner’s conclusion that there were no arguable breaches of either a systemic duty or an operational duty to protect Jackie’s life by either the care home or the healthcare professionals involved and, therefore, the Coroner had not erred in refusing to allow the jury to comment on the circumstances of Jackie’s death, to identify failings, and to make critical findings.
Muriel Maguire is represented by Partner Anna Thwaites and Associate Joanna Bennett of Bindmans LLP, with Counsel Jenni Richards KC and Nicola Kohn from 39 Essex Chambers.