UK: ECHR finds prison death violated Articles 2 and 13

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The European Court of Human Rights held on 14 March 2002 in the case of Paul and Audrey Edwards v the United Kingdom (no 46477/99) that there had been a violation of Article 2 (right to life) of the European Convention on Human Rights as regards the circumstances of their son Christopher Edwards' death; that there had been a violation of Article 2 as regards the failure to conduct an effective investigation; there had been a violation of Article 13 (right to an effective remedy).
Christopher Edwards was "tentatively" diagnosed as schizophrenic in 1991. He was arrested on 27 November 1994 and taken to Colchester police station after making "inappropriate" suggestions to women in the street. He was later remanded in custody at Chelmsford prison, initially on his own. On 28 November Richard Linford was placed in the same cell as Christopher Edwards. Linford had a history of violent assaults, including assault on a cell mate in prison. He was diagnosed schizophrenic. Each cell had an emergency call button, which lit up a green light outside the cell and activated a buzzer and a red light on the landing. At 9pm on 28 November 1994, a prison officer became aware that the buzzer linked to the cell was malfunctioning, but did not report this. Shortly before 1am on 29 November 1994 the prison officer responsible for D landing heard a buzzer sound but no red light on the landing control panel. Some time later he heard continuous banging on a cell door and on going to investigate saw the green light on outside Edwards' and Linford's cell. Officers entered the cell to find that Linford had kicked and stamped Christopher Edwards to death.
In 1995, a private, non-statutory inquiry was commissioned, which reported on 15 June 1998. It concluded that ideally Edwards and Linford should not have been in prison and in practice ought not to have been sharing a cell. It found a "systemic collapse of the protective mechanisms that ought to have operated" to protect Christopher Edwards. It identified a series of shortcomings, including poor record-keeping, inadequate communication and limited inter-agency co-operation. The applicants were advised that there were no civil remedies available to them, and on 25 November 1998 the Crown Prosecution Service maintained that there was insufficient evidence to proceed with criminal charges.
The European Court of Human Rights was satisfied that information had been available which identified Richard Linford as suffering from a mental illness with a record of violence which was serious enough to merit proposals for compulsory detention and that this, in combination with his bizarre and violent behaviour on and following arrest, demonstrated he had been a real and serious risk to Christopher Edwards when placed in his cell.
Regarding the measures which the authorities might reasonably have taken to alleviate that risk, the Court observed that the information concerning Linford's medical history and perceived dangerousness ought to have been brought to the attention of the prison authorities. It was not. The Court concluded that the failure of the agencies involved in the case (medical profession, police, prosecution and court) to pass on information about Richard Linford to the prison authorities, and the inadequate nature of the screening process disclosed a breach of the state's obligation to protect the life of Christopher Edwards. There had therefore been a violation of Article 2.
The Court observed that no inquest was held and that the subsequent conviction of Richard Linford did not involve examination of witnesses as he pleaded guilty to manslaughter and was subject to a hospital order. Considering whether the inquiry had provided an effective investigative procedure, the court noted that the inquiry had heard a large number of witnesses and reviewed in detail the way the two men were treated, but the inquiry had no power to compel witnesses and as a result two prison officers (one of wh

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