Scope of inquiry Minute October 2021 plus appendices [pdf, 720 KB]
...investigation arose because the State was responsible for the deaths of the victims. Her 26 R (Middleton) v West Somerset Coroner [2004] UKHL 10, [2004] 2 AC 182. 27 At [19]. 28 At [20]. 29 At [30]. See also Osman v The United Kingdom [1998] ECHR 101 at [67] where the accused pleaded guilty so the matter was considered by the European Commission of Human Rights to establish the facts and make findings. 30 Osman v The United Kingdom [1998] ECHR 101. 31 At [107]. 20 Honour h...