Discrimination in prison medication dispensing – objective justification and an unjustified failure to think about it
9 October 2026
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The following piece was also posted here on 1 Crown Office Row’s Quarterly Medical Law Review
Birmingham Community Healthcare NHS Trust v Ibrahim [2026] EWHC 2468 (KB)
In Ibrahim, Mr Justice Soole upheld a Judge’s decision that the Defendant Trust had breached the Claimant’s rights under Article 14 of the European Convention of Human Rights (‘ECHR’) when it failed to adopt an alternative procedure for dispensing Codeine outside of daylight hours during Ramadan in 2019. In reality, the Trust’s arguments were completely undermined by the fact that no one had actually thought about the issue at the time.
Background
The Claimant was a Muslim prisoner. The Trust was responsible for providing primary healthcare at the prison. The Claimant was prescribed Codeine. This was provided each day under supervision at a medicine hatch. The hatch operated during fixed hours each morning and afternoon. Generally, there was no system for providing medication under supervision outside those hours. There were, however, separate arrangements in certain other circumstances, such as prisoners arriving at the prison late in the evening.
Unless exempt, Muslims are required to fast during daylight hours throughout the month of Ramadan. This includes not consuming oral medication. In 2019, the hatch opening times were during daylight hours. The arrangements ultimately put in place by the Trust were that the Claimant was temporarily prescribed alternative painkillers during Ramadan which he was permitted to take in his cell, rather than under supervision at the hatch. The Judge found as fact that the temporary use of these alternative painkillers had no adverse impact on the Claimant.
The claims were for an unlawful interference with the right to respect for private life under Article 8 ECHR; an unlawful interference with the right to manifest religious beliefs under Article 9 ECHR; and unlawful discrimination on the grounds of religion in violation of Article 14 ECHR, when read with Articles 8 and 9 ECHR. It is unclear why no discrimination claim was brought under the Equality Act 2010.
Judgment below
His Honour Judge Najib held that Articles 8 and 9 ECHR were engaged but not violated. The Claimant was able to and in fact did fast throughout Ramadan. He was provided with alternative medication which, ultimately, had no adverse effect. There was no challenge to these findings on appeal.
However, the Judge also held that there was a breach of Article 14 ECHR. He identified the questions to be asked as set out by Baroness Hale in R (Stott) v Secretary of State for Justice [2018] UKSC 59 at [207]:
- does the treatment complained of fall within the ambit of one of the Convention rights;
- is that treatment on the ground of some “status”;
- is the situation of the claimant analogous to that of some other person who has been treated differently; and
- is the difference justified, in the sense that it is a proportionate means of achieving a legitimate aim?
Question two was not disputed: the ground was religion. On the other issues, the Judge held that: i) the treatment complained of fell within the ambit of Articles 8 and 9 ECHR – there was a “more than merely tenuous connection” [39]; ii) the Claimant’s situation was analogous to other prisoners who had been prescribed medication which could only be taken under supervision [51]; and iii) the failure to put in place alternative arrangements was not in pursuit of the legitimate aim of ensuring security and preventing the proliferation of opiate based and other controlled substances [68], but was instead due to an ‘apparent’ lack of resources and/or a need to prioritise limited resources [69] which was not made out on the facts [76]. As such, the Article 14 ECHR claim succeeded.
Appeal
The Trust’s appeal challenged the Judge’s conclusions on ‘ambit’ and ‘objective justification’ – i.e., the first and fourth of the Stott questions.
As to the ambit issue, the challenge “centred on the Judge’s finding of fact that Mr Ibrahim had not suffered withdrawal or any other adverse symptoms in consequence of not taking Codeine” [80]. Soole J rejected this argument for the following three reasons: firstly, ‘ambit’ and ‘interference’ are separate concepts – treatment can come within the ambit of an ECHR right even if that right is not violated [89]; secondly, the appropriate test is “whether the criticised measure or treatment has a more than merely tenuous connection to the core value(s) of a substantive Article” (emphasis added) [90]; and, thirdly, it is not necessary, for ‘ambit’ purposes, to establish that the relevant treatment had an adverse effect and the Judge was right to focus on the connection between the treatment complained of and the substantive ECHR rights [91]-[92].
The more substantial challenge was to the conclusion on objective justification. The Trust’s arguments all centred on the allocation of resources – that the Judge “failed to identify the allocation of scarce resources as a legitimate aim; and thus failed to take resources into account when considering proportionality” [105]. Moreover, to the extent that the Judge did consider the allocation of resources, he wrongly held that the Trust’s evidence that alternative procedures would have been impractical amounted to no more than a ‘bare assertion’ [97].
In rejecting these arguments, Soole J first sounded a warning against “the dangers of undue textual criticism” in the context of a necessarily lengthy judgment [106]. Giving a fair reading to the judgment as a whole, Soole J held that the Judge had indeed considered the allocation of resources. His rejection of this issue was based not on principle, but on the facts.
The reality was that no one had in fact turned their mind to the possibility of providing the Claimant with his medication by some alternative procedure. The evidence of Trust witnesses on resources and practicality “did not reflect the actual reasoning of anyone at the time”, but simply their beliefs that it would have been difficult if anyone had thought about it. This belief was itself “undermined” by the fact that alternative arrangements were made in other situations, e.g., for prisoners arriving at the prison late. In such circumstances, the Judge was entitled to conclude that the Trust’s evidence amounted to a ‘bare assertion’ and, in fact, it was “difficult to see how the Judge could have reached any other conclusion” [114].
It followed from this central finding that the resources had not formed any part of the Trust’s aim in not making alternative arrangements for the Claimant. As such, it was not necessary to consider proportionality but, had it been, the same finding of fact “would or should equally have compelled the conclusion that the test of proportionality was not met” [125].
Comment
There are some useful illustrations of principle in Soole J’s judgment, particularly on the ‘ambit’ issue. Firstly, that the appropriate test is whether the criticised measure or treatment has a “more than merely tenuous connection” to the core value(s) of a substantive ECHR Article. Secondly, that it is not necessary to establish that the relevant treatment had any adverse effect.
However, this was a case where “the very particular facts and circumstances” [126] carried the day. In some ways, this counted against the Claimant. The Article 8 and 9 ECHR claims were dismissed on the basis that the Claimant had been able to fast and did not experience any real issues as a result of temporarily not taking Codeine or having to take an alternative painkiller. The position would inevitably be very different if a Muslim prisoner was receiving some other medication such that this would have been a problem – i.e., so that they would effectively need to choose between their religion and their health.
The central finding of fact though was the “overall failure by anyone to apply their mind to [the issue]” [118]. The practical lesson for institutions is that it will be very difficult to justify discriminatory treatment as a proportionate means of achieving a legitimate aim, if the legitimate aim has been retrospectively manufactured. Before the question of whether issues of practicality and resources might amount to a legitimate aim in principle, there is the preliminary question of whether such issues were in fact the reason for the discriminatory treatment. If, in reality, the reason was simply that no one thought about it, then evidence of hypothetical impracticality or resource constraints is unlikely to carry much weight. Had the Trust taken even some perfunctory steps to investigate whether alternative arrangements would have been feasible, it seems likely that it would have been given a reasonably wide margin of appreciation. However, having taken none, it was “in an inherently weak position on its margin of appreciation” [121]. A further practical point is that, where a claim relates to a failure to make an exception, then other exceptions – such as for late-arriving prisoners in this case – are likely to carry significant weight and will need to be carefully explained.
Lance Baynham is a barrister at 1 Crown Office Row.
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