R (Rizvi) v HM Assistant Coroner for South London [2025] EWHC 3014 (Admin) judgment 17^th Nov 2025 here

It has been a long journey for Mrs Rizvi who may now have exhausted all avenues in her attempts to show that the police breached an Article 2 duty owed to her daughter.  Twelve and a half years ago Sabina Rivzi was the innocent victim of a gang shooting as she drove away from Bexleyheath Police Station, having picked up her boyfriend after a police interview.  A High Court judge has now forcefully concluded that, having held an Article 2 compliant investigation and inquest, the Assistant Coroner[1] was entitled to consider it unsafe to leave any findings of fact to the jury regarding acts or omissions by the police. The Claimant’s counsel’s “island-hopping expedition in a sea of extensive evidence” did not persuade Mr Justice Foxton that it was arguable that the Coroner’s assessment that it would be unsafe to do so had been unreasonable in the Wednesbury sense.

This case importantly delineates the ambit of the Art 2 procedural duty on coroners. It is exactly what it says on the label – a duty of procedure and not one of outcome.  It is quite a low threshold that triggers the procedural duty [2] to investigate an arguable Art 2 breach. But the hurdle to be surmounted before making any positive finding is somewhat higher once the evidence has been heard. In many cases a thorough exploration of all the evidence will reveal there is no state shortcoming that needs to be left to the jury, let alone reflected in the inquest’s conclusion.

A London NHS Trust v DT (by her litigation friend the Official Solicitor) and YT [2025] EWCOP 36.  21 October 2025, Judgment here 

Just occasionally a judgment from another jurisdiction can make you scratch your head very hard if you try and look at it through coronial eyes. This recent decision from the Court of Protection around brain stem testing and the neurological diagnosis of death has managed to leave your blogger with full blown dermatillomania.

But let’s first start with Schrödinger’s cat – a 90 year old thought experiment exploring superpositions in quantum mechanics (an entirely probabilistic system, which bears little relationship to the generally understood deterministic laws of physics that human life generally operates under). Radioactive atoms are considered by some quantum physicists to be in two states at once: decayed and not decayed and only switching to one of those to states when observed. To test this quantum theory Schrödinger sealed his theoretical cat in a box along with some theoretical unstable atoms and a batch of poison, thereby linking poor kitty’s fate to a random subatomic event. In the paradox the cat is to be considered simultaneously alive and dead  until the box is opened and its state is observed.

BUT NO, I hear you scream, life is deterministic not probabilistic, and therefore the cat is either alive or dead even before one looks in the box. On looking you are simply observing what already has occurred. It’s not that the cat is both dead and alive, it’s just that we don’t KNOW if it’s dead or alive.  Of course that was exactly Schrödinger’s point, as he sought to diss his fellow physicists with this fluffy feline paradox.

On one view of this present case, the law seems to have led the judge to approach the decision making regarding the unfortunate woman patient as if she too were a sub-atomic particle within a probabilistic system, who could be both alive and dead at the same time.

 

HM Senior Coroner for South London v Alexei [2025] EWHC 2768 (Admin), 7 October 2025, judgment here

The question of which evidence to call at an inquest is a matter for the coroner alone. The coroner should call sufficient evidence and conduct a sufficient inquiry to answer the statutory questions. However, the Courts have repeatedly emphasised the wide area of judgment that a coroner enjoys in deciding who to call to give evidence.[1] It is a matter of coronial discretion whether their investigation has uncovered sufficient evidence on a key point to allow for an adequate inquest to then follow.  ‘Sufficient’ is not a particularly high standard, an adequate investigation will be good enough.  The decision regarding whether further evidence should be sought will often be made bearing in mind a number of factors, including: (i) the rule 8 requirement to complete an inquest within six months; and (ii) how likely it is that any additional evidence that might be obtained will contradict the evidence that is already available.

However where a coroner goes ahead on the basis of only a provisional or preliminary  medical expert report there is always a risk that the expert’s final opinion might differ.  Unfortunately for the coroner holding this inquest, that is precisely what occurred.

Commencing 6 November 2025

The Centre for Contemporary Coronial Law at the University of Greater Manchester  is pleased to announce that the highly successful Coronial Law short course will be offered again, starting on Thursday, 6th November 2025.

Designed for practitioners working in, with, or aspiring to join the coronial service, the course blends clear legal foundations with practical, court-facing skills to build confidence in real investigations and inquests. It is ideal for coroner’s officers, hospital coronial liaison staff, legal representatives, those seeking coronial roles (including newly appointed coroners), and others involved in the inquest process.

Course Schedule:

• 6th November 2025
  Lecture 1 – Coroners
  Professor Alan Walsh (Retired HM Area Coroner, Manchester West)
• 20th November 2025
  Lecture 2 – Investigations
  Professor Christopher Dorries OBE (Retired HM Senior Coroner, South Yorkshire West)
• 4th December 2025
  Seminar/Case Studies
  Professor Christopher Dorries OBE
• 18th December 2025
  Lecture 3 – Inquests (Part I)
  Professor Alan Walsh
• 8th January 2026
  Lecture 4 – Inquests (Part II)
  Professor Alan Walsh
• 22nd January 2026
  Lecture 5 – Article 2
  Timothy Brennand
  HM Senior Coroner, Manchester West
• 5th February 2026
  Mock Inquest and Celebration
  Professor Christopher Dorries OBE & Professor Alan Walsh

Course Details:

• All sessions will be conducted via MS Teams from 18:00 to 20:30.
• The cost per session is £50, or £300 for the complete series.
• To book your place:

  Book the Coronial Law Short Course

Contact Information:

For more details, please contact Dr Alicia Danielsson.

Email: CoronialLaw@greatermanchester.ac.uk

R (Ferguson) v  HM Assistant Coroner for Sefton, Knowsley & St Helens and the Chief Constable of Merseyside Police [2025] EWHC 1901 (Admin) 23 July 2025 –  judgment here

Q1: What strength of evidence will make it arguable that an article 2 duty has arisen and/or make it arguable that a duty has been breached, so as to trigger an Art 2 compliant inquest?

Q2: For a mandatory jury to be required need there be an inappropriate act or omission by police, or is their mere involvement enough?

The answer to both these questions is now clarified in this latest Judicial Review decision from the High Court which underlines how, in respect of the “low arguability threshold” for Art 2 engagement, low really does mean low. But, before any commentary, first a confession: this blogger could not stop herself fangirling Mrs Justice Hill as she read through this judgment.  It is a beautiful exposition of how to write a clear and accessible judgment.  It is long, at 46 pages, as Hill J is no slouch and the factual analysis is quite detailed. But her Ladyship’s “Article 2 in overview” section (see paras 14-37) is as clear an exposition of the relevant law on the engagement of Art 2 procedural duties as you will find anywhere. Indeed, inquest practitioners might as well just copy and paste the text into their skeleton arguments (or coroners into their own judgments) to save themselves a lot of time,  as it is really not worth trying to explain this complex law any more succinctly than you will find in Hill J’s 23 neat paragraphs. It would be ridiculously presumptuous for this blog to even try to summarise it any further, beyond noting that Hill J clarifies that the low threshold of ‘arguability’ which will engage the procedural Art 2 duty applies not only to the question of any breach of a substantive art 2 duty, but also to whether any duty arises in the first place.

The meat of this case is, as with many cases, the application of the law to the unique facts and looking at whether the coroner had correctly applied that low arguability threshold in coming to his decision.

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