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

Fecha: 17-Nov-2025

The course of the Inquest

The course of the Inquest

29.

This was an unusual inquest, following the conviction of Paul Asbury for Sabina Rizvi’s murder (an event which would in the ordinary course have discharged the state’s responsibility to investigate an unlawful death). The key issue which led to the decision to resume the Inquest, notwithstanding the trial and Paul Asbury’s conviction, was the outstanding issue of whether the state, and in particular the Police, were in some respect responsible for Sabina Rizvi’s death.

30.

In February 2019, the Senior Coroner for South London ruled that the operational duty arising under Article 2 of the ECHR was arguably engaged in relation to Sabina Rizvi, engaging s.5(2) of the 2009 Act. In reaching that conclusion, the Senior Coroner accepted submissions from the Rizvi family that it was arguable that:

the Police were or ought to have been aware that there was a real and immediate risk to life; and

ii)

the Police failed to take reasonable measures to avoid the risk.

31.

The Coroner was appointed as Assistant Coroner to conduct the Inquest. Cathryn McGahey KC was appointed counsel to the Inquest (“CTI”).

32.

From 2019, the family were represented by by solicitors, first Imran Khan and subsequently Leigh Day LLP. The family’s counsel team at the Inquest comprised Rajiv Menon KC and Christopher Williams.

33.

At a pre-inquest review on 13 January 2020, CTI set out the proposed scope of the Inquest to include:

Whether the Police knew or ought to have known that an attack would or might take place and whether steps could or should have been taken to prevent it; and

ii)

Whether the Police deliberately or inadvertently notified Paul Asbury and/or others of the whereabouts of Mark Williams.

34.

The Jury was sworn in February 2024.

35.

The evidence was completed in the morning of day 11 of the Inquest (21 March 2024).

36.

The Jury were dismissed that morning, and the Coroner then heard oral submissions from the various represented parties (having previously been provided with submissions in writing) on the issue of which issues should be left to the Jury. It is important to record the subject-matter of those submissions, taking the written submissions first.

37.

CTI addressed:

The test to be applied when determining which matters to leave to the Jury.

ii)

The nature of the substantive Article 2 duty.

iii)

The three key issues identified as being within the scope of the Inquest:

Whether the Police deliberately notified Paul Asbury and/or others of the whereabouts of Mark Williams.

Whether the Police inadvertently notified Paul Asbury and/or others of the whereabouts of Mark Williams.

Whether the Police knew or ought to have known that an attack would or might take place and whether and what steps could or should have been taken to prevent it.

iv)

Reflecting the focus of the Inquest from its resumption, on the third issue the submissions outlined the applicable legal principles for a substantive Article 2 breach, breaking the issue down into three factual issues:

Whether the Police knew or ought to have known at the time of the existence of a real and immediate threat to the life of Ms Rizvi.

Whether the Police knew that the risk arose from the criminal acts of Paul Asbury and his associates.

Whether the Police failed to take measures within the scope of their powers which, judged reasonably, might have been expected to avoid that risk.

The submissions summarised the evidence by reference to the following headings: the existence of a risk from Paul Asbury; whether any risk was “real and immediate”? (in which context reference was made to the elements of Article 2); was there any real and immediate threat to the life of Ms Rizvi; and what action could the police reasonably have been expected to take to protect Ms Rizvi from any threat to her life from Paul Asbury?

vi)

Under a heading “Summary on Article 2”, the submissions then identified six factual issues in respect of each of which the Coroner would need to be satisfied that there was “evidence on which the jury, properly directed, could properly conclude that the police officers failed to discharge their operational duty to Ms Rizvi”:

There was a risk to the life of Ms Rizvi.

The risk was real and immediate (and, in this context, was a risk of murderous attack occurring shortly after Mark Williams and Ms Rizvi left the police station).

The risk came from Paul Asbury and his associates.

The police were or ought to have been aware of (a) to (c).

There were steps that the police could reasonably have been expected to take to prevent the risk from materialising.

The police failed to take those steps.

vii)

It was those six factual issues on which it was submitted that the Coroner would need to consider whether there was sufficient evidence for those issues to be left to the Jury (see in particular paragraph 61 of CTI’s written submissions).

38.

The Rizvi family submission identified three factual matters to be left to the Jury as arguably having caused or contributed to Sabina Rizvi’s death:

“Mr Florio inadvertently confirming to Paul Asbury … that Mark Williams … was in custody at Bexleyheath Police Station.”

ii)

“Mr Florio and Mr Horner concluding that there was no real and immediate risk to [Mark Williams] life when granting him bail.”

iii)

“Mr Florio asking the custody officer to grant [Mark Williams’] bail (rather than keeping him in custody pending further enquiries)”.

39.

Like CTI, the family’s submissions addressed the requirements for liability under Article 2, and what was necessary “to show the Osman operational duty was breached”. The family’s submissions as to the issues where there was sufficient evidence for them to be put to the Jury had an obvious Osman /Article 2 flavour:

that the Police ought to have known “that there was a real and immediate risk” to Mark Williams’ life;

ii)

that the Police failed to take reasonably available measures which could have had a “real prospect of altering the outcome or mitigating the harm” (cf Opuz v Turkey [2003] 36 EHRR 31, [136]);

iii)

“Mr Florio and Mr Horner concluding that there was no real and immediate risk to [Mark Williams’] life when granting him bail more than minimally contributed to Sabina’s death”.

40.

There were oral submissions on 21 and 22 March 2024. These included submissions from all parties as to the requirements of the Article 2 operational duty:

Ms McGahey KC as CTI identified a key issue for the Coroner to consider as being “whether there was an Article 2 breach”, and used the shorthand “Article 2” to refer to the second of the three issues which the family contended should be left to the Jury.

ii)

Mr Menon KC for the family noted that if the Coroner “were to find that Article 2 is no longer engaged in this case, after your examination of the evidence and applying the Galbraith test to it …. There may well be no possibly causative matters to leave”. He made submissions on “the Osman duty and how it should be approached”, specifically linking the second of the two points the family wished left to the jury to the Osman test. Mr Menon KC made no submission that Ms McGahey KC’s submissions betrayed an error in addressing the requirements for a substantive Article 2 breach in the context of the Coroner’s Galbraith ruling. On the contrary, his own submission stated “if you were to conclude that Article 2 is engaged in this case …”

iii)

Counsel for the Police framed their Galbraith submission as being that there is “insufficient evidence upon which the jury could be permitted to return narrative findings critical to the police on the Osman issue.” They too made extensive submissions on the requirements for liability for breach of the operational Article 2 duty.

iv)

Counsel for Roberto Florio and Thomas Horner also referred to Article 2 in the context of identifying the issues “that would require … sufficient evidence for any question to be left to the jury”.

In reply, Mr Menon KC for the family submitted that there is “a proper evidential basis for not reversing the decision that you made some time ago that Article 2 was engaged, which ultimately is the fundamental point.”

41.

In short, it is clear that all who participated in the Inquest conducted themselves on the basis that, if the evidential threshold was met, the issues for the Jury would be the factual predicates for the Article 2 operational duty, with the Galbraith test being applied by the Coroner to determine if the evidential threshold was met. Not surprisingly, that shared understanding of the issues was reflected in the Coroner’s ruling.