Eileen Henshaw, R (on the application of) v HM Assistant Coroner for Derby and Derbyshire

In an Article 2-compliant inquest, a coroner may leave potentially causative circumstances to the jury even where causation cannot be established on the balance of probabilities, particularly where an admitted failing may have contributed to the death. The coroner must not fetter that discretion by treating the absence of proven causation as determinative.

However, relief remains discretionary. A record of inquest need not be quashed where the evidential gaps cannot be filled, the possible causal effect is speculative or de minimis, and no reasonable jury could reach a materially different conclusion. The same principles apply to decisions about calling witnesses.

Georgina Henshaw died suddenly in custody at HMP Foston Hall. An Article 2-compliant inquest recorded the medical cause of death as sudden cardiac arrhythmia and the conclusion as natural causes.

Her mother challenged the coroner’s directions and summing-up. The grounds concerned the omission of accidental death as a possible conclusion, the exclusion of matters including an allegedly inadequate prison officer check, an incomplete GP summary and failures to carry out ECGs, and the refusal to call a witness from the community GP practice.

The central issues were the scope of the jury’s inquiry into the circumstances of death, the treatment of potentially causative but unproven failings, the coroner’s discretion to call witnesses, and the appropriate remedy.

1. Ground 1 dismissed. The jury’s Box 3 conclusion amounted in substance to a narrative conclusion. The sequencing of consideration of natural causes was academic because the jury went on to provide a narrative account.
2. The coroner was entitled not to leave accidental death to the jury on the basis that the incorrect insertion of the I-gel had, at most, hastened an inevitable death by a few minutes. Applying the distinction in R v Birmingham and Solihull Coroner Ex p. Benton, the case fell within the scenario where treatment failed to prevent death from an underlying fatal condition. The I-gel’s causal impact was de minimis.
3. The 8:25 am prison officer check was properly excluded. Any inadequacy was speculative and could not convincingly be shown even possibly to have caused or contributed to death.
4. Ground 2 succeeded in part. The admitted failure to arrange an ECG in May 2018, together with the evidence that long QT syndrome might have contributed to the arrhythmia, was at least a tenable potentially causative circumstance within the ambit of an Article 2 inquest. The coroner unlawfully fettered her discretion by treating the absence of proof of causation as excluding the issue from the jury.
5. Ground 3 succeeded in principle. The coroner also fettered her discretion when deciding whether to call a witness from the GP practice. She could nevertheless lawfully have concluded, on a properly directed basis, that a witness was unlikely to assist after the lapse of time.
6. Following R (Tainton) v HM Senior Coroner for Preston and West Lancashire, declaratory relief was sufficient. The record was not quashed because the evidential gaps could never be filled, further investigation would be disproportionate and unnecessary, and no reasonable jury could reach materially more favourable conclusions.

The claim was therefore declared well-founded to the limited extent identified, but the application for a quashing order and a fresh inquest was refused.