Investigating potential breaches of the right to life: ‘Unified’ investigation processes not necessary

Summary The European Court of Human Rights has clarified the scope of a State party’s obligation to investigate a death in circumstances involving a potential breach of the right to life.

In Pearson v United Kingdom [2011] ECHR 2319, the Court clarified that, where government employees or agents are implicated in a death, the State is bound to adequately investigate the death to establish the relevant facts and to hold persons accountable, as appropriate. Those obligations may be met by, or shared between, several different processes and authorities. There is no requirement for a single body, such as a coroner’s court, to deal with all aspects of an investigation.


Circumstances leading to the death

The case was brought by Jean Pearson, the mother of Kelly Pearson. Kelly had a history of mental health problems associated with alcohol and substance abuse. She died from a self-administered drug overdose aged 30.

Shortly before her death, in November 1999, Kelly was arrested for being drunk and disorderly in West Yorkshire. The police searched their database which revealed a warrant against Kelly that was erroneously described in the database as ‘outstanding’ (the warrant had actually been discharged several weeks earlier). Because of this mistake, Kelly was transferred from West Yorkshire, where she lived with her mother, to London. The mistake came to light when Kelly presented at a London magistrates’ court.

After realising the error, Kelly was released from custody and a probation officer gave her enough money for a bus fare back to West Yorkshire, although Kelly made the decision to remain in London.

The following day, while still in London, Kelly sought help from a mental health worker and a general practitioner, whom she knew. Kelly refused to take the prescription medication given to her by the GP and left the medical centre in an agitated state. Approximately two hours later, Kelly collapsed in the street. She died in hospital a short while later.

Investigations following the death

A coronial inquest was held in 2002. Although the coroner heard a substantial amount of evidence about Kelly’s background and the events leading up to her death, the scope of the inquest was confined to matters directly causative of her death. The Coroner determined that Kelly died from ‘methadone, diazepam and alcohol poisoning’.

At the inquest stage, the Applicant asked the Coroner to deal with a range of matters, such as:  Who or what was responsible for the mistake in the police database? Why there were no safeguards to prevent such errors? Who was responsible for securing basic support to a vulnerable woman who had been falsely imprisoned and unlawfully transported hundreds of miles from her home? The Coroner maintained that it was not his role to apportion blame and did not allow the inquest to deal with these broad issues. (Note: Had Kelly died after the commencement of the UK’s Human Rights Act 1998 on October 2000, then the scope of the inquest would have been broader.)

In addition to the coronial inquest, a number of other agencies also investigated and reported on the death. The West Yorkshire Probation Board, for example, produced a report. The London Probation Authority also investigated and reported on the complaint insofar as it related to the London area. The Prisons and Probation Ombudsman also conducted an investigation following an appeal by the Applicant.

The Applicant also brought civil proceedings against a number of parties involved, including the Greater London Magistrates Court Authority, which settled.

Complaint to the European Court

The Applicant submitted that, because of its narrow scope, the coronial inquest did not satisfy the State’s investigative obligations under article 2 (Right to life) of the European Convention. The Applicant further argued that the State was obliged to investigate the death in a unified way, rather than through a range of disparate legal process.


The Court reiterated the well-established principle that where lives are lost in circumstances that potentially engage the responsibility of the State, the State is under an obligation to adequately investigate those deaths. The obligation arises under the right to life.

Such an investigation must contain two key elements: fact-finding and accountability.  Specifically, the Court said:

The essential purpose of such investigation is to secure the effective implementation of the domestic laws which protect the right to life and, in those cases involving State agents or bodies, to ensure their accountability… The form of investigation required to achieve these purposes will vary according to the circumstances of the particular case.

The Court clarified that the State was not required to meet each of these requirements through a single, unified investigation procedure. It said:

It cannot be said, as the applicant suggested, that there should be one unified procedure satisfying all requirements: the aims of fact-finding and accountability may be carried out by or shared between several authorities, as long as the various procedures provide for the necessary safeguards in an accessible and effective manner.

The Court found that the coronial inquest into Kelly’s death – although limited in scope – was sufficient to satisfy the State’s fact-finding obligation. This was because the coronial inquest involved an independent tribunal subjecting the relevant facts to a thorough review and exposing those facts to public scrutiny. Moreover, the Applicant was legally represented.

The Court considered that although the coronial inquest process did not deal with accountability, the Applicant’s ability to bring a civil claim in negligence against those people who she held responsible, when coupled with the possibility of disciplinary measures against government employees, was satisfactory to meet the State’s obligations under this part of the test.

For the reasons set out above, the Court declared the Applicant’s claim inadmissible.

The decision can be found online at:

Emma Purdue is on secondment to the Human Rights Law Centre from Lander & Rogers