Limited scope for fresh inquests

A recent judicial review claim will be of interest to inquest practitioners where the High Court examined the Coroner’s inquest into the death of a prisoner in custody.

The judgment in R (Eileen Henshaw) v HM Assistant Coroner for Derby and Derbyshire considered three aspects of the Article 2 – compliant inquest that took place in October 2023.

Background

The inquest concerned the death of Ms Henshaw at HMP Foston Hall. 

Ms Henshaw was prescribed anti-psychotic medication. The medication was associated with long QT syndrome, which has potential associated risks of irregular heartbeat, fainting and sudden death.

Ms Henshaw’s GP records contained a warning that she should not be issued further anti-psychotic medication without a psychiatrist’s review, but the summary sent to the prison did not contain the warning, and the medication was issued.

A request for blood tests and an ECG was made in May 2018, but these were not carried out. On 31 August 2018, Ms Henshaw passed away following a cardiac arrest.

The judicial review claim

The family’s application challenged the following aspects of the inquest conclusion on the basis that:

• The direction given by the Coroner to the jury in relation to natural causes was wrong.
  
  
• Failings regarding an ECG were not to form part of the findings, and the Coroner preventing the jury from reaching conclusions on factual matters central to the inquest, and/or from entering judgmental conclusions of a factual nature, was wrong.
  
  
• The Coroner failed to make Ms Henshaw's community GP an interested person in the inquest and/or not call a live witness from the GP practice.

They sought to quash the inquest conclusion and seek an order for a fresh inquest.

High Court decision

We set out the Judge’s findings across the three challenged decisions.

Inquest conclusion

At an inquest, the Coroner must record a conclusion as to how a person died.

In Ms Henshaw’s inquest, the Coroner directed the jury that there were two possible conclusions; a short-form conclusion of natural causes, or a narrative conclusion. The Coroner did not leave accidental death as a possible verdict. The jury delivered a narrative conclusion.

The Coroner’s directions in relation to natural causes were challenged by Ms Henshaw’s mother. Although the Judge remarked that the Coroner’s directions were not “particularly clear or easy to follow”, the Judge concluded that it would be inappropriate for the Record of Inquest to be quashed and a fresh inquest be held on this basis.

Factual matters

The Coroner directed the jury not to consider the “wider circumstances”, including the failure to conduct the ECG and blood tests, and what the results may have shown.

Ms Henshaw’s mother argued that this was an admitted failing which may have had a causative impact on Ms Henshaw’s death, and so it should have been considered by the jury.

The Judge concluded that the Coroner’s direction amounted to an unlawful fettering of discretion, highlighting that, “possible causes, particularly in the context of admitted failings, are potentially within the ambit of an Article-2 compliant inquest”. However, the Judge concluded that this was not sufficient to quash the Record of Inquest and hold a new inquest.

The GP’s role

Ms Henshaw’s mother challenged the Coroner’s decision not to make the GP an interested person, and/or not to call a live witness from the GP practice.

However, the Judge decided that the Coroner could lawfully decide that a GP witness was unlikely to assist so many years after the events.

Decision

On the basis of these findings, the Judge directed the parties to draw up an order recording the errors in the inquest (“declaratory relief”). However, the Coroner refused the application for a quashing order, and so a fresh inquest will not take place.

Comment

This was described as a “difficult case which would have challenged even the most experienced coroners”. It demonstrates the high threshold that exists before a fresh inquest will be directed.

Our content explained