YOUNGER - United Kingdom (Nº 57420/00)

Decision 7.1.2003 [Section II]

The applicant’s son, S., committed suicide in custody in February 1999 at the age of 20. He was arrested for driving offences and taken to a police station. There he met with a solicitor, whom he informed of his heroin addiction. The solicitor advised him that if he saw the police surgeon in order to obtain medication, his addiction would not be kept confidential and would diminish his chances of being released on bail. Although S. was apprehensive about spending the night in custody, the solicitor described him as rational and articulate at that point. The following morning, S. asked to see a doctor. He did not give details, stating instead that it was on a personal matter. He informed the police officer on duty that he preferred to see a doctor before going to prison, where a medical consultation would be more difficult. The police officer and the police surgeon formed the view that this was not an emergency request and that there was no need to delay S.’s transfer to the Magistrates’ Court, where he could, if he wished, see a doctor later on. The police officer later stated that S. had not displayed any sign of physical or mental distress during his detention at the police station. S. was handed over to Group 4 (a private company responsible for escorting persons to and from the courts and prison) to be taken to court. The police officers informed the Group 4 employees about the request for a doctor but were told that it was unlikely that a doctor would be called, as the company would have to bear the costs. After arriving at the court building, S. repeated his request for a doctor. He also told his custodians about his addiction. The senior staff member tried to arrange for the hearing to be held as soon as possible. A community psychiatric nurse arrived during the morning, but did not contact S. When S.’s solicitor came to see him, he advised him that he could see a doctor at that point without jeopardising his chance of bail at the imminent hearing. He found S. to be calm, rational and responsive, although worried at the prospect of prison. The hearing took place in the afternoon and S. was remanded to a young offenders’ institution, where he had been previously. The guard escorting him stated that he was in good sprits up until bail was denied, whereupon he became very quiet. A different account was given by S.’s brother, who recalled him crying in the courtroom and screaming in the corridor. His solicitor met with him after the hearing and found him to be very unhappy about being sent to the institution. He mentioned suicide, a remark that his solicitor took seriously. Immediately after the interview, the solicitor informed the senior staff member of the failure to arrange for his client to see a doctor. She replied that she had been unaware of the request and that, in any event, she had been trying without success to find a doctor for another detainee. The solicitor also informed her of his concern at his client’s allusion to suicide. A staff member was sent to check on S., who, in the seven minutes since the end of the interview with his solicitor, had hanged himself by his shoelaces from the open hatch in the door of his cell. Staff attempted to resuscitate him. He was taken in an ambulance to hospital where he died the next day.

An official inquiry was held into the death. It found, inter alia, that certain significant information had been omitted from the official form that accompanies detainees: repeated requests for a doctor, the fact of S.’s addiction, the change in his behaviour following the hearing. The report of the inquiry also referred to a memorandum circulated to Group 4 staff in the month before S. died, instructing them to ensure that cell door hatches were kept shut while the cell was occupied. The memorandum did not specify that the reason for the instruction was to try to prevent suicides. The potential danger of leaving hatches open was originally identified by an official circular in 1968. The staff who had dealt with S. told the inquest that they were unaware of the memorandum and that it had been policy at that time to leave hatches open. The senior staff officer testified that, nearly one year after the death of S., she had still not been informed of the purpose of the memorandum. The applicant was advised by her solicitor and by counsel that she had no viable cause of action for damages and would thus fail to qualify for legal aid. She was therefore unable to bring legal proceedings to establish the liability of her son’s custodians for failing to prevent his death or to seek damages for his death.

Inadmissible under Article 2: The issue to be examined was whether the authorities ought to have known there was a risk of suicide, it being accepted by the applicant that as soon as the authorities had actual knowledge they had reacted promptly. Although the failure to make a written note of S.’s requests to see a doctor and of his drug addiction was a matter for concern, this information was not sufficient to put the authorities on notice that S. was a suicide risk. He had no history of mental health problems or suicidal tendencies, and his behaviour during his detention showed no particular sign of physical or mental stress. The applicant’s argument that if her son had been seen by a doctor or the psychiatric nurse there was a real possibility that the authorities would have become aware of his vulnerability to the risk of suicide was too speculative. A "real possibility" test put the threshold for determining whether there has been a violation of Article 2 far too low. Even if such a test were applied, it would be pure speculation to conclude that, prior to the hearing, a medical professional would have alerted the authorities and averted the tragic outcome. In all the circumstances, it could not be concluded that the authorities ought to have known that S. was a real and immediate suicide risk before his solicitor alerted them to his client’s state of mind. In the absence of foreseeability, the authorities were not in breach of their positive obligation under Article 2 to protect S.’s life.

The applicant further contended that, in view of the enhanced risk of suicide in a custodial situation, the safest course for the authorities would be to adopt a minimum standard of care for all prisoners, including the closure of cell door hatches. However, the failure to observe the instruction regarding hatches did not of itself give rise to a violation of Article 2, given that the authorities had no actual or imputed knowledge that S. was a real and immediate suicide risk. Moreover, such a proposition was unsubstantiated: the statistical data available indicated that suicide among detainees in the United Kingdom was rare. To regard all prisoners as suicide risks would place a disproportionate burden on the authorities as well as unduly restrict the liberty of the individual. Article 2 did not impose any such minimum standard upon the State in the absence of any other evidence that an identified individual was a known suicide risk. Nevertheless, the Court expressed its particular disquiet that the instruction regarding cell door hatches had not been followed and that, almost one year later, staff were still unaware of the reason for the instruction.