UK: The Case of Matthew Raveneau
Article 2 Applies Even Though Death Occured After Release From Prison

Matthew Raveneau took his own life on the 26^th or 27^th November 2002, four days after being released on bail from Belmarsh Prison.

The deceased’s mental health had deteriorated during 2002 and in October 2002 he held his children hostage in their home in an effort to get himself shot by police snipers. He did not threaten the children and they were released unharmed. He was prosecuted for false imprisonment and during this period his partner made several requests for him to be given help for his mental health problems.

He was remanded into custody at HMP Belmarsh on 12^th November 2002. The Prisoner Escort Record identified him as being at risk of suicide or self harm. However, the nurse and doctor whom he saw in Reception at Belmarsh did not pick up on this and he was recorded as having "no particular medical concerns".

As a result of a bail application the deceased was released to his family (although not to his partner and children). It was at his sister’s house that he was found hanging on 27^th November 2002.

HM Coroner, Selina Lynch listed the Inquest for October 2003. However, at this hearing the family raised a number of concerns about the actions of public authorities in failing to treat the deceased’s mental health problems. The Coroner therefore adjourned the Inquest on the basis that a Pre-Inquest Hearing would decide the issue of whether Article 2 of the European Convention on Human Rights applied to the Inquest.

Article 2 provides that "Everyone’s right to life shall be protected by law…" Member states are required not merely to refrain from taking life intentionally but also to take reasonable measures to safeguard life¹. A person in custody is in a vulnerable position and the way in which he or she is treated must be subject to strict scrutiny under the Convention.² There have been various cases showing that the State has been in breach of its duty to protect life where inadequate measures were taken to prevent death where it should have been apparent that a prisoner was suicidal.³

Despite the fact that Mr Raveneau did not die in custody, at the Pre Inquest Hearing in June 2004, the Coroner ruled that indeed the death did come under the scope of Article 2 following the House of Lords decision in Middleton⁴. Although she decided that the actions of the police could not be criticised, she decided that the actions of the prison were relevant. She gave two reasons for coming to the conclusion that it was an Article 2 Inquest which were, firstly that the deceased had recently been in prison and second, because of the concerns raised by the family that the deceased had not received the appropriate care.

As a result of the decision at the Pre Inquest Hearing the Coroner widened the scope of the Inquest to deal with the question not only of "by what means" the deceased came to die but also "in what circumstances" death took place. The Coroner pointed out in her Judgment that per Middleton the issue of "neglect" was not relevant and it was her practice in Article 2 cases to highlight State failings that may have contributed to the death. Expressly Jamieson⁵ did not apply.

The Inquest took place in September 2004. Despite identifying failings at the prison the Coroner did not feel that these contributed to the death. The deceased was examined by a number of doctors both in police custody and in prison. Although the index incident itself should have given cause for concern there was very little other medical evidence that the deceased was at risk of suicide or self harm. There were a number of other intervening events. The deceased applied for bail which was supported by his family and a surety was paid. He was granted bail to his uncle’s house. Although he did not in fact stay at his uncle’s house the authorities were not informed of this.

The Coroner reached an "open" verdict stating that "the deceased hanged himself…….. whilst the balance of his mind was acutely disturbed….."

Although the Coroner did not conclude that any failing by the prison contributed to the death there were significant advantages to the broadening of the scope of the inquiry.

The family, who felt there were lost opportunities to save the life of the deceased, were entitled to explore various aspects of the treatment he received. As such they were satisfied that the Inquest represented a full and thorough investigation of the death. If the scope of the Inquest had been narrower and only the immediate circumstances of death had been looked into they would undoubtedly have unanswered questions.

Furthermore, a fuller investigation is more likely to lead to failings being identified which can then be remedied. There is no need for the failing to have contributed to the death. What may be a side issue in one case could be a life and death matter in another. The Coroner indicated that she would have made a Rule 43 Recommendation in relation to the prison’s failure to take account of the warning on the Prisoner Escort Report about the deceased’s risk of suicide, however, she said that she had been assured by HMP Belmarsh that the system for recording and acting upon such warnings had already been significantly tightened as a result of another death.

Although suicide and self harm amongst prisoners has been recognised as a problem and preventative steps are being taken, there is still little being done about vulnerable people who leave prison. The Howard League states⁶ that factors associated with heightened suicide risk, including, alcoholism, substance misuse, financial and accommodation problems, mental health problems and break down in family relationships, occur disproportionately in ex-offenders. Yet very little or nothing is being done to help them to readjust to life outside prison.

Where suicidal inmates are prevented from killing themselves in prison only because of constant monitoring or the removal of ligature points it must follow that once these precautions have been removed the risk of suicide is significant. The Home Office has identified the particular problem of short sentences where prisoners do not have the benefit of sentence planning or post-release supervision.

The Howard League report refers to the case of Lester Christopher Shore who killed himself within hours of release from HMP Pentonville in July 1999. Although he was recognised as highly vulnerable in prison no steps were taken to protect his life on release. Despite his family’s concerns about the actions of the prison, no prison investigation was carried out and the remit of the Inquest was restricted to the immediate cause of death.

There was no prison investigation into the death of Matthew Raveneau either. However, the Coroner was persuaded that it was proper to conduct a fuller investigation. The Inquest of Matthew Raveneau shows that coroners should now be willing to look into the wider circumstances of the death even where death does not occur in custody. In terms of the prison investigation, the Prisons and Probation Ombudsman’s terms of reference⁷ exclude investigating deaths of those released from prison, although the Ombudsman, Stephen Shaw, has in fact recently indicated that he would investigate some cases of those who die after release.

Because of the lack of independent investigations in cases where people die after release from prison, historically, systemic failings have not been highlighted or remedied. Now Article 2 dictates that where a vulnerable person is released from custody the obligation to protect his or her life does not stop at the prison gates. Whether that responsibility lies with the prison, the courts, the probation or the mental health services is another matter.

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