AC-2024-LON-003241 - [2025] EWHC 3014 (Admin)

Fecha: 17-Nov-2025

Did the Coroner ask herself the right question?

Did the Coroner ask herself the right question?

78.

First, that the Coroner asked herself “the wrong question” when stating:

“The question is does any issue remain under Article 2 to leave to the jury to consider? All parties agree on the law which I must apply, with a difference of emphasis and at times interpretation. All parties agree on the test in Galbraith”.

79.

This was said not to be the correct test because “the question of whether the Article 2 duty is engaged arises quite separately from the question of whether there are issues which can properly and safely be left to the jury”. As the matter was developed in oral argument, Mr Stanbury sought to distinguish the legal issues relating to Article 2, which he said were not matters for the Jury, and the issue of evidential sufficiency. He suggested that the Coroner had been led into error by confusing these two separate matters.

80.

I am satisfied that this ground is not arguable, and I suspect that, as a complaint, it would have come as something of a surprise to the family’s legal team at the Inquest:

The relevant issue for the Coroner was whether, applying the relevant test, there was sufficient evidence for certain issues to be left to the Jury. Those issues were the factual issues which were relevant to a substantive Article 2 complaint.

ii)

As I have explained, the issue of potential Article 2 liability had been front and centre of the Inquest after it had been resumed following Paul Asbury’s conviction, and the focus of all parties after the completion of the evidence was whether issues of fact relevant to Article 2 liability should be left to the Jury and, if so, which. For that reason, all counsel (including counsel for the family) made submissions to the Coroner about the Osman test, and framed their argument in relation to the issues which should or should not be left to the Jury by reference to the factual predicates of Osman liability. No counsel (including counsel for the family) suggested that this was in any way inappropriate.

iii)

The Ruling addressed the various factual issues to which the various parties had drawn attention in the context of the Article 2 substantive duty, for the purpose of determining whether the evidential threshold for leaving the factual basis of Article 2 liability to the Jury was met. That did not involve (as Mr Stanbury at one point seemed to be suggesting) simply deciding if there was an arguable Article 2 claim. That was relevant to the issue of what type of inquest (Article 2 or Jamieson) was required to discharge the procedural Article 2 duty, but by the end of the evidence, matters had moved beyond that issue. At this stage, the issue for the Coroner was not one of arguability, but of evidential sufficiency applying the Galbraith test.

iv)

The fact that coroner’s juries do not themselves determine civil liability (s.10(2) of the Act) does not, as Mr Stanbury submitted, have the effect that a coroner is only concerned with what is arguable when leaving issues to the Jury. The Jury is concerned with making factual findings on particular issues, not determinations of liability, albeit particular factual findings will obviously be relevant to certain forms of civil liability and, as in this case, the ingredients of particular forms of liability will have a very strong influence on those issues a coroner is asked to leave to the jury.