TRANSCRIPT

Welcome to this LSM Lecture Plus on Reading the Part A case, and guidance on preparing the
case note. You will need to have the set case in front of you as you listen to the lecture, so that
you can refer to it and make notes.
This Lecture Plus is designed to help you with reading the case of R (Maguire) v HM’s Senior
Coroner for Blackpool and Fylde [2019] EWHC 1232 (Admin), and to give you some assistance in
preparing your case note. This case forms the basis of Part A of the Legal System and Method
examination.
Note that the claimant has appealed the decision of the High Court in this case. There is no
decision yet on that appeal, but it may be decided before you submit your case note or before
the exam. You are not required to know anything about the outcome of any appeal, or to read
the judgment in any appeal, for the purposes of the exam. Make sure you are reading the High
Court judgment – check the citation reference which will be different for any appeal decision.
You’re required to submit a case note on the Maguire case, via the VLE. If you fail to submit the
case note by the relevant deadline, then Part A of your Legal System and Method examination
will not be marked.
This case note, which is probably the first case note you have written, will be longer than any
case note you will write in the future. The reason for this is that you’re writing this case note
specifically to prepare for Part A of the LSM examination. Usually, if you’re writing a case note to
learn a case for an exam, you will write the case note to remind yourself of the basic points and
the decision the court reached. Here, you’re going to need to cover all the points you might be
asked about in the examination. We have provided a sample case note, based on the famous
contract law case of Carlill v Carbolic Smoke Ball Company. This illustrates the level of detail you
need to think about including in your case note. You can find the sample case note on the VLE.
Here is the information you need to provide in the case note. This is all the essential information
that will help you to fully understand the case and answer questions on it in the examination.
For many cases you can get someone else’s notes but they will never help you like your own
notes, for the simple reason that you will not have been through the process of reading and
refining the material to create notes that suit you and improve your understanding. Be careful of
doing a general internet search to find notes or commentary about a case – what you find may
not be accurate or may be out of date. Going through the process of making your own notes
really is the best way of developing your own understanding of the case, and it is this that you
will need for your examination.
When you are reading the case and writing your case note, you will need to find a way to reduce
the words in the judgement for the purpose of your notes. You might decide to use bullet points

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or a more dynamic diagram such as a mind map or a timeline. You need to work out what
approach works best for you.
Some of the basic information is very straightforward. You should have no trouble providing the
case name and citation. The case name is R (Maguire) v HM’s Senior Coroner for Blackpool and
Fylde. You may not have seen this style of case name before, so I will explain what it means. This
is the style of case names for judicial review cases. I will come on to discuss judicial review a little
later in the lecture, although it may be that you already know something about it from studying
public law. All you need to know at the moment is that when a claimant brings a judicial review
case they are technically asking the Crown to do so, which explains the ‘R’ (standing for Regina,
the Queen) at the beginning of the case name. The actual claimant’s name is shown in brackets
after the R and the case is said to be ‘on the application of’ that person.
The citation is [2019] EWHC 1232 (Admin). This citation is known as a neutral citation, and we can
look at this to see what information it provides. The case was decided, or reported, in 2019. EW
tells you the jurisdiction, which is England and Wales. The letters HC tell you it’s a decision of the
High Court. Admin means that the case was heard in the Administrative Court. This is the part of
the High Court that hears judicial review cases. The numbers provide a unique number for this
case in the year 2019.
The judges are named on the front page of the case. You will see that three judges sat in this
case, and that they are Lord Justice Irwin, Mrs Justice Farbey and His Honour Judge Lucraft QC,
sitting as a High Court judge. This last judge is a circuit judge, who would usually sit in the Crown
Court and the County Court. The front page of the case explains that for this case he is sitting as
a High Court judge.
You should now be able to complete two parts of your case note: the case name and citation,
and the court and the judges.
The next part of the case note is also fairly straightforward. Here, you need to identify the parties,
which are all identified on the front page of the judgment. We see that the claimant, or the
person bringing the case, is Muriel Maguire. Don’t forget that in judicial review cases like this
one, the case is technically brought by the Crown. The ‘on the application of’ wording shows
who the actual claimant in the case is. The Queen or her representatives are present in name
only and take no actual part in the case.
This is the modern way of naming judicial review cases, which was introduced in 2001. You will
see a different format for judicial review cases before 2001, and you can see examples of this in
the module guide.
But who is the defendant in this case? This is a little more complicated. The defendant is Her
Majesty’s Senior Coroner for Blackpool and Fylde. You will see that there are also a number of
‘interested parties’ listed. Under the Civil Procedure Rules (Rule 54.1), an ‘interested party’ in a
judicial review case is any person, other than the claimant and defendant, who is directly
affected by the claim. In certain circumstances, these interested parties can take part in the legal
proceedings.
Paragraph 8 of the Maguire judgment notes that a number of interested parties at the inquest
were joined to the judicial review proceedings. Throughout the judgment, you will see that the
role of each of the interested parties in the case is explained. In paragraph 29 of the judgment, it
explains that the principal opposition to Mrs Maguire’s claim was in fact provided by one of the
interested parties, United Response, who managed the care home where many of the facts of
the case took place.

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Let’s check where we are with writing the case note. So far, we have the case name and citation,
the court and judges, and the parties. The next parts of the case note are more complex, and
require you to identify the material facts, questions of law and legal issues, and the judges’
reasoning. You’ll find it helpful to have the judgment to hand, and you should make your own
notes as I work through some of the detail.
The court helpfully provides some headings in its judgment. This is not so in all court decisions –
there is no template for writing judgments in English law, although modern judgments
increasingly use headings which makes them much easier to follow. Many judgments follow a
pattern of: facts, followed by relevant law and then applying the law to the facts of the case and
reaching a conclusion. Throughout my discussion of the case, I will refer to paragraph numbers
in the judgment.
One thing to say at the outset is that in this case, there is a single judgment of the court, to
which all three judges who heard the case contributed (see paragraph 1). When reading other
cases, you will see that they may have a lead judgment by a named judge, and that the
transcript will show who has given that and whether other judges agree or disagree and have
anything to add.
The basic facts of the case are relatively straightforward. The case is about a woman called Jackie
who died while in care. There is quite a lot of detail given in the case about the facts. You don’t
need to learn all the precise details of the case – your focus should be on the material facts.
At an early stage of reading a case, you can’t always work out what the material facts are, and
you will need to continue reading the judgment. Only when you know what the facts are and
see how the court reaches its decisions and what facts were considered significant will you be
able to work out what the material facts are.
Working out what the material facts are is an important skill in a common law legal system,
because of the doctrine of binding precedent. This is the system whereby judges have to follow
certain previously decided cases. It relies, among other things, on lawyers being able to identify
what facts were material in the previous cases. There is more information about material facts
and the operation of precedent in chapter 3 of the module guide and associated readings.
Before you complete the ‘facts’ section of the case note, there are some areas of law it will be
useful for you to understand. These are all mentioned in the judgment but they may be
unfamiliar to you.
You will see reference in the judgment to the Mental Capacity Act 2005 and the Deprivation of
Liberty Standards, or DOLS for short.
You don’t need to know the detail of the Mental Capacity Act or the Deprivation of Liberty
Standards, and you don’t need to do any extra research about them for the exam. But you will
need to know a little bit about them to understand the case.
Section 2(1) of the Mental Capacity Act defines mental incapacity in this way: ‘a person lacks
capacity in relation to a matter if at the material time he is unable to make a decision for himself
in relation to the matter because of an impairment of, or a disturbance in the functioning of, the
mind or brain.’ In paragraph 10 of the judgment, the court explains that Jackie had been
deprived of her liberty under the Mental Capacity Act, and could therefore not leave her care
home without supervision.
The Mental Capacity Act allows the deprivation of liberty of a person in a care home or a
hospital, if certain conditions are met. These conditions and other safeguards are set out in
Schedule A1 of the Mental Capacity Act, which contains the Deprivation of Liberty Standards.
The Deprivation Of Liberty Standards establish a process for authorising a deprivation of liberty.

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They aim to ensure that adults who lack capacity to consent are only deprived of liberty if this is
considered to be in their best interests. The requirements for the deprivation of liberty include
(among others) the age requirement, the mental health requirement, the mental capacity
requirement and the best interests requirement.
If the relevant requirements are met, then a ‘standard authorisation’ can be made. This allows
the person to be deprived of their liberty in a care home or hospital for a period up to 12
months. Paragraph 14 of the judgment explains that, on the basis of assessment reports, Jackie
had been deprived of her liberty and was subject to DOLS on a one year standard authorisation
in April 2016.
The Deprivation of Liberty Standards have in fact been heavily criticised and are due to be
replaced by a scheme known as the Liberty Protection Safeguards, in spring 2020. The relevant
legislation is the Mental Capacity (Amendment) Act 2019. This does not affect anything about
the Maguire case or your case note.
You will see in paragraph 4 of the judgment that an inquest was held into Jackie’s death.
Paragraphs 23 – 26 explain what happened at the inquest.
An inquest is a public judicial inquiry to investigate a set of facts concerning a person’s death.
Most deaths do not require an inquest – it is only required if a death is of an unnatural, violent or
unexplained nature, or where the deceased was in the care or custody of the state, as was the
case in Maguire.
Inquests are presided over by a Coroner. A Coroner is an independent judicial officer. In certain
circumstances an inquest may be heard by a jury as well as by a Coroner. Although the default
rule is that there will not be a jury, there is an exception where the death has taken place in state
custody or care. You will note that the inquest in Maguire was a jury inquest.
In more complex cases the coroner may hold a series of pre-inquest review hearings (PIRH). At
pre-inquest review hearings, written and oral submissions are made to establish key issues such
as who the interested persons are, the scope of the inquest, expert evidence and so on.
Where a person has died while in the care or custody of the state, an inquest may engage Article
2 of the European Convention on Human Rights – the right to life. Whether or not the inquest
should have been an ‘Article 2 inquest’ is the central question in Maguire.
The claim in Maguire was brought by way of judicial review in the Administrative Court. The
judicial review was of the decision made by the Coroner at the Inquest.
As you may know from studying public law, judicial review is a type of court proceeding in which
the courts review the lawfulness of a decision or action of a public body. It is a challenge to the
way in which a decision has been made, not to whether the decision itself was correct. There are
a number of grounds for judicial review, which are broadly: illegality (unlawfulness), irrationality
and procedural impropriety.
The decisions of a Coroner at an Inquest are subject to judicial review.
Now that you’ve had some background information, you can proceed to make notes on the
material facts of the case.
The facts of the case are set out in paragraphs 9 - 22 of the judgment. You will also find the
section headed Introduction helpful in paragraphs 1 – 8. In addition, you will need to understand
the procedural history of the case - the inquest and background to the judicial review claim. You
will need to summarise the material facts of the case. There is a lot of detail about the facts, so
you need to pick out and summarise the most salient points.

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Let’s look at the legal issues in this case, as set out in paragraph 28 of the judgment. These are
the legal claims made by the claimant as their grounds for the judicial review.
There are two legal arguments made by the claimant. The first is based on Article 2 ECHR; the
second is based on neglect. The claimant argued firstly that the coroner erred in law by
determining that Article 2 did not apply (because of the recent Parkinson case), and that Article 2
should have been left to the inquest jury. The claimant’s second argument was that the coroner
erred in law by not leaving the question of neglect to the inquest jury.
Both of these legal issues are discussed in the judgment, and the headings used helpfully
structure the judgment, so you can see where each point is being discussed.
You have so far considered the material facts, and the legal grounds for the judicial review made
by the claimant. Now we come onto the court’s decision. As already noted, the first claim is
based on article 2 ECHR and is discussed in paragraphs 30 – 49. Article 2 provides that everyone’s
right to life shall be protected by law. This right places corresponding duties on states. The
Maguire case explains what the different aspects of these state obligations are.
The next step is to read paragraphs 30-49 of the judgment and make notes. The questions on
this slide will help you to understand what the court decided about the claim under article 2.
In paragraphs 30-41, the court sets out the legal framework of this part of the case. The court
usefully reviews the law on the state’s obligations under article 2, and how the law has
developed state duties over time through case law. Think about what the scope is of state duties
under article 2.
You will find you need to read this section several times, making notes and thinking about how
the law has developed incrementally, through the cases, and what principles have emerged
from the cases.
In paragraphs 42-43, the court discusses the parties’ submissions on article 2. Think about what
each side argued, and try to summarise it succinctly for your own notes. Note that the claimant
made two different arguments in the alternative.
Also be aware that, as stated earlier in this lecture, the coroner, although the defendant, was
neutral in the case. The counter-arguments were put by the first interested party, United
Response, who managed the care home where Jackie lived before her death.

Paragraphs 44 – 49 set out the court’s analysis and conclusions on article 2, and provides the
detailed reasons for the court’s decision on this ground of challenge. Read this section very
carefully and try to follow the court’s line of reasoning for its decision. Try to formulate the ratio
of this part of the case. Remember that the ratio of the case is the court’s reason for deciding,
and is the part of the judgment that will bind future courts. Finally, make a note of what the
court actually decides – is this ground of challenge successful or not?
You should now have made notes on the first ground of challenge relating to article 2 of the
European Convention on Human Rights.
The second ground of challenge relates to the decision of the Coroner not to leave a finding of
neglect to the jury.
Before you make notes on this second ground of challenge, it will be helpful to explain some
background to help you.
‘Neglect’ is one of several possible conclusions that a Coroner can come to at the end of an
inquest, as a cause of death. Neglect has been the subject of guidance from the Chief Coroner

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(the head of the Coroner system). This guidance is set out in the Chief Coroner’s Guidance on
Conclusions, Guidance No 17, which you will see referred to in the judgment (you don’t need to
read the guidance itself separately, just what is said about it in the judgment). Paragraph 57 of
the judgment contains an excerpt from the Guidance which explains what ‘neglect’ means in
law, and the legal framework applied at the inquest.
You will also see references to the Coroner’s decision that it would not be “Galbraith safe” to
leave the issue of neglect to the jury. This is a reference to the test in inquests which decides
whether coroners should leave matters to the jury. The test is: whether there is enough evidence
to leave a particular conclusion to the jury, and whether it would be safe on the evidence for the
jury to reach this conclusion.
With these points in mind, you should now be able to read and understand paragraphs 50-58,
and understand the coroner’s decision on neglect at the inquest (in paragraphs 50-51), the
submissions made about this decision before the Administrative Court (paragraphs 52-54), and
the Administrative Court’s decision on neglect as a ground of challenge (paragraph 58).
You should now almost have completed your case note. As well as the case name and citation,
the court and judges, and the parties, we have looked at identifying the material facts, the
questions of law and legal issues, and the judges’ reasoning and detailed reasons for the
decision.
Finally, make sure you have noted the decision of the court on both legal issues, and the
conclusion – see paragraphs 49, 58 and 59-60.
Read the entire judgment several times and make sure you are very familiar with it. And recall
that the case note you write is for you to prepare for Part A of the examination.
As I said at the start of this lecture, my aim was to help you with reading the Maguire case and to
give you some assistance in preparing your case note. It’s up to you to actually prepare the case
note and hopefully by now it might be a bit clearer from listening to this lecture. There is now
the opportunity to engage with the activities on the Discussion Forum while it is open. Thank
you for listening, and good luck with writing your case note.

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