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

At [41], it was noted that the issue of causation raised by the case, to which the Galbraith or Galbraith-plus test fell to be applied, was:

“whether, on the balance of probabilities, the conduct in question more than minimally, negligibly or trivially contributed to death”

At [42], that a coroner had a discretion, but not an obligation to leave to the jury “causes of death that are merely possible and not probable”.

The Divisional Court concluded that the coroner had been right to conclude that he was not under a duty to leave the issue of causation of the admitted failings of the prison medical authorities to the jury ([71]).

However, the Divisional Court concluded that the coroner had erred in not recording those admitted failings in the inquest record ([80]).

In R (Worthington) v HM Senior Coroner for the County of Cumbria [2018] EWHC 3386 (Admin), [46]-[49], the Divisional Court rejected a challenge to the decision of a coroner of this kind, stating “to set out a negative conclusion in the determination of a section 5(1) matter (e.g. that something suggested as causative did not cause the death) is not proscribed by the statutory provisions; and, in the circumstances of a particular case, it may be appropriate or even obligatory to ensure the legal requirements for a such a determination are met … The question of how the deceased came by his death is clearly wider than merely finding the medical cause of death – a coroner is required to “enquire into acts and omissions which are directly responsible for the death” …We are unconvinced by Mr Thomas's submission that it is sufficient to record such findings in a ruling; and that a coroner is, in the circumstances of this case, positively prohibited from including them in the determination of the “how” question.”

In Dove v HM Assistant Coroner for Teesside and Hartlepool [2023] EWCA Civ 289, [70], the Court of Appeal stated:

“[E]xisting authority shows that it is open to a coroner to record the facts which contributed to the circumstances which may or may not in turn have led to death: the unattended open window in Longfield, the sexual assault in Worthington . These cases provide examples of the wide discretion conferred on coroners to establish the background facts, and then determine whether those facts were or were not causative of death. These are examples of coroners tailoring the scope of an inquest to the issues in the case in order to discover the 'substantial truth'.”