Information Note on the Court’s case-law 29

April 2001

Keenan v. the United Kingdom - 27229/95

Judgment 3.4.2001 [Section III]

Article 2

Article 2-1

Life

Prison suicide: no violation

Article 3

Inhuman treatment

Suicide of mentally ill prisoner – adequacy of care: violation

Article 13

Effective remedy

Availability of remedy in respect of prison suicide: violation

Facts : In 1993 the applicant's 28-year old son, who had a history of disturbed behaviour, including self-harm, was imprisoned following his conviction for an assault on his girlfriend. He was placed in an unfurnished cell and put on a 15-minute watch after his cell-mate reported that he had fashioned a noose from a bed-sheet. Thereafter, several attempts were made to readmit him to ordinary location, but each time he was returned to the health care unit. Following an assault on two hospital officers, he was agai n placed in an unfurnished cell. He was nevertheless certified fit for adjudication in respect of the assault and was consequently placed in segregation in the punishment block. He indicated that he was feeling suicidal and received counselling, and was ag ain transferred to an unfurnished cell and placed on a 15-minute watch. He was returned to the segregation unit after apparently improving. About ten days later – nine days before his expected release date – he was found guilty of the assault and given 28 additional days in prison. The following morning, both the doctor and a visitor found him calm and relaxed, although disappointed. However, that evening the applicant's son was found hanged in his cell.  At the inquest, a verdict of death by misadventure w as recorded. The applicant's legal aid was withdrawn in the light of counsel's opinion that, notwithstanding the grave breach of duty by the prison service in keeping a mentally ill prisoner in a punishment cell without proper medical monitoring, an action in negligence would not succeed.

Law : Article 2 – It is common ground that the applicant's son was mentally ill. Although it is disputed whether he was schizophrenic and thus a high suicide risk, the prison authorities were aware that the problem was chro nic and involved psychosis with intermittent flare-ups and his behaviour after admittance to prison put them on notice that he exhibited suicidal tendencies. The authorities therefore knew that his mental state was such that he posed a potential risk to hi s own life although, as his behaviour showed periods of apparent normality, it cannot be concluded that he was at risk throughout his detention. On the whole, the authorities responded reasonably to the conduct of the applicant's son, placing him in hospit al care and under watch when suicidal tendencies appeared. There was daily medical supervision and there was no reason to alert the authorities on the day of the incident that attempted suicide was likely. Thus, it is not apparent that the authorities omit ted to take any reasonable step. The argument that increased stress resulting from the disciplinary punishment should have been foreseen is speculative and the issues concerning the standard of care prior to the death fall to be examined under Article 3.

C onclusion : no violation (unanimously).

Article 3 – It cannot be disputed that the applicant's son suffered anguish and distress during the period in question, but it is not possible to distinguish with any certainty to what extent the symptoms resulted fro m the conditions of detention. However, this is not determinative of the issue whether the authorities fulfilled their obligation to protect him from treatment or punishment contrary to Article 3:  treatment of a mentally ill person may be incompatible wit h the standards imposed by Article 3 even if specific ill effects cannot be identified. The absence of entries in the medical records in the 10-day period leading up to the applicant's son's death shows an inadequate concern to maintain full and detailed r ecords of his mental state and undermines the effectiveness of any monitoring or supervision process. This, combined with the lack of informed psychiatric input, discloses significant defects in the medical care provided to a mentally ill person known to b e a suicide risk. The belated imposition of a serious disciplinary punishment which may well have threatened his physical and moral resistance is not compatible with the standard of treatment required in respect of a mentally ill person and must be regarde d as constituting inhuman and degrading treatment.

Conclusion : violation (five votes to two).

Article 13 – The applicant's complaints are "arguable" for the purposes of this provision in connection with both Article 2 and Article 3. As far as the applicant's son is concerned, he committed suicide the day after the imposition of the disciplinary pun ishment. There was no remedy which would have offered him the prospect of challenging the punishment and even assuming judicial review would have provided a means of challenging it, it would not have been possible for him to obtain legal aid and lodge an a pplication within such a short time period. The internal avenue of complaint similarly takes an estimated six weeks. Moreover, if he were not in a fit mental state to make use of any available remedies, this would point to the need for automatic review in such cases. As far as the applicant herself is concerned, it is agreed that the inquest was not an effective remedy for the purposes of Article 13. With regard to an action in negligence in respect of injury suffered before death, the Court is not persuade d that a finding of negligence by the courts would in itself be capable of furnishing effective redress and it does not accept that adequate damages would have been recoverable or that legal aid would have been available. As for anguish and fear, there is no evidence that this would be regarded as an "injury". Furthermore, as the mother of a non-dependent adult, the applicant cannot claim damages under the Fatal Accidents Act. In cases of a breach of Articles 2 and 3, compensation for non-pecuniary damage s hould in principle be available as part of the range of possible remedies. No effective remedy was available to the applicant which would have established where responsibility for the death lay, and this is an essential element of a remedy under Article 13 .

Conclusion : violation (unanimously).

Article 41 – The Court awarded the applicant £7,000 (GBP) for non-pecuniary damages in respect of her son, to be held by her for his estate, and £3,000 in her personal capacity. It also made an award in respect of cos ts and expenses.

© Council of Europe/European Court of Human Rights This summary by the Registry does not bind the Court.

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