Looking back at 2025: Judicial Reviews of Coronial Decisions

Looking back at 2025: Judicial Reviews of Coronial Decisions

As the new year begins, our inquest lawyers reflect on the key judicial reviews of Coronial decisions in 2025.

Three themes have been consistent: 

1. Coroners should avoid speculative lines of investigation.
2. A Coroner’s procedural discretion (particularly around scope and expert evidence) remains broad; and
3. Article 2 of the European Convention of Human Rights (Article 2) engagement continues to be tightly controlled and highly fact‑specific.

Together, the cases below provide valuable guidance for practitioners navigating the increasingly complex landscape of coronial law and an insight for interested persons involved in inquest proceedings.

O’Brien v HM Assistant Coroner for Sefton, Knowsley and St Helens [2025] EWHC 362 (Admin) 

Key takeaway: This judgment highlights that speculative events should not form part of the Coroner’s investigation and a possibility must have some evidence to support it. 

Linda O’Brien died on 9 May 2020 after falling from a window of her flat. Her former partner, who was subject to a restraining order (RO), was the only other person present when she fell. One month earlier, on 7 April 2020 (“the April incident”), police attended her flat after a disturbance report and found her former partner present but failed to arrest him because they were unaware of the RO nor did they make enquiries to establish the existence of the RO (“the omission”). The Assistant Coroner limited the inquest’s scope to the event in May and considered the April incident for background purposes only. 

The family brought judicial review proceedings contending the omission should have been in scope and expert evidence obtained to establish what the “likely progress and outcome of any prosecution would have been”. The High Court found the Coroner’s decision to limit scope was rational as it could not be found that the omission “more than minimally, negligibly or trivially” contributed to death. The Court also ruled the expert evidence sought would be “purely speculative and of no probative value.”

R (Glaister & Carr) v HM Assistant Coroner for North Wales [2025] EWHC 167 (Admin)

Key takeaway: This judgment involved the tragic death of a scout during a camping trip in North Wales. The High Court ruled the Coroner properly directed the jury that “unlawful killing” was a conclusion they should consider. Please see our article published on 17 February 2025 for further details.

R (Gamesys Operations Ltd) v HM Senior Coroner Inner London South [2025] EWHC 659 (Admin)

Key takeaway: This judgment reinforces that Coroners have broad authority when selecting expert witnesses. 

Gamesys Operations Ltd (“Gamesys”) operates online gambling sites that were used by Mr Lee Adams prior to his death from an overdose of medication. Mr Adams’ family submitted that the Coroner should appoint Professor Gerada as an expert witness to establish if Mr Adams suffered a gambling disorder and if so, whether this contributed to his death. Gamesys objected with impartiality concerns due to Professor Gerada’s “anti-gambling” views and suggested an alternative expert Dr Frazer, a Consultant Psychiatrist. The Coroner decided to appoint both Professor Gerada and Dr Frazer as expert witnesses. 

Gamesys sought to challenge the decision to appoint Professor Gereda by judicial review. The High Court dismissed the claim and held that the Coroner had “conducted an exhaustive process” in selecting the experts and noted the High Court will rarely “entertain a challenge to the exercise of a coroner's discretion”. It was also ruled that the “appearance of bias” test applicable to judges does not apply to experts whose duty is to the Court.

R (Robinson) v. HM Assistant Coroner Blackpool & Fylde [2025] EWHC 781 (Admin)

Key takeaway: In this judgment the High Court was reluctant to broaden the scope of the Article 2 duty and confirmed that the engagement of Article 2 will always be fact specific. 

Mr Robinson died in March 2021 after swallowing a drug package during a police restraint causing fatal airway obstruction. His family submitted at the inquest that Article 2, the right to life, should be engaged. This would allow the jury to make judgmental findings in their findings of fact and conclusion. The Coroner decided against this as he did not consider there was a “real and immediate risk” to Mr Robinson and noted the police acted lawfully when exercising their duty. The jury concluded Mr Robinson died by “Misadventure”. 

The family sought judicial review and argued there should be an extension of the “automatic” cases that engage Article 2 where the deceased dies of an unnatural death during “involuntary” custody or whilst under the control of the state.

The High Court dismissed the claim and reaffirmed that automatic Article 2 engagement is confined to the established category of cases, such as deaths in custody by suicide or an unlawful act of a police officer. The Court rejected proposals to expand these categories to include misadventure, noting such events may be unpredictable and not attributable to an omission by an agent of the state. 

R (Bailey) v HM Senior Coroner for East London  [2025] EWHC 1637 (Admin)

Key takeaway: This judgment clarifies that where an inquest is adjourned due to criminal proceedings, Article 2 procedural obligations can be satisfied via other investigations conducted by the state. It also confirms that Coroners have wide discretion in deciding whether to resume inquest proceedings and that challenges to such decisions are unlikely to succeed.

 An inquest was formally opened into the death of 14-year-old Jaden Bailey in January 2019 after he was killed in East London, but was adjourned shortly after to allow for the criminal proceedings to take place. The perpetrator was found guilty of Jaden’s death and sentenced to life imprisonment. Following this, in December 2019, the Coroner issued a certificate that the inquest was not to be resumed. The family applied to resume the inquest on the grounds that Article 2 was engaged, however this was denied by the Coroner who considered that any Article 2 obligations had been met through the various cumulative investigations. 

Upon judicial review, the High Court agreed with the Coroner and held that there was no reason why the criminal investigation and the serious case review were incapable of satisfying the state’s Article 2 duties.

R (Ferguson) v HM Assistant Coroner for Sefton, Knowsley & St Helens and the Chief Constable of Merseyside Police [2025] EWHC 1901 (Admin)

Key takeaway: This judgment highlights the distinction between a low threshold for triggering Article 2 investigations and a higher threshold for conclusions. It also reminds Coroners that a jury will likely be required where there is an “act or omission” of a police officer. 

Police attended to James Farley after a public concern report. Mr Farley said he was drunk, suffered psychosis, but did not intend self-harm and planned to go home. Reassured by this, the officers saw him leave and departed the scene. Twenty minutes later, Mr Farley jumped to his death from a car park. An internal review by the Police Force found that more could have been done to provide “robust safeguarding” of Mr Farley. 

The Coroner ruled Article 2 was not engaged, applying a high threshold that officers could not have known or ought to have known of the suicide risk. The Coroner also determined the mandatory requirement to empanel a jury where there has been an “act or omission” of a police officer was not met as this should be interpreted as an “inappropriate” step by the police.

The family initiated judicial review and the High Court overturned the Coroner’s ruling. First, the High Court clarified there is a low threshold for engaging Article 2 if there is an “arguable” breach and found failure to safeguard Mr Farley arguably breached that duty. It also held the Coroner’s interpretation of an “act or omission” was wrong and therefore a jury was required. 

R (Rizvi) v HM Assistant Coroner for South London [2025] EWHC 3014 (Admin)

Key takeaway: This judgment highlights the difference between engaging Article 2 as a duty to investigate and its application to the outcome of that investigation.

Sabina Rizvi was murdered in 2003 shortly after leaving a police station having collected her boyfriend who had been detained for a police interview. The inquest resumed years later after the criminal trial. The Coroner ruled that Article 2 was engaged as there was a “real and immediate” risk to Ms Rizvi’s life. However, the Coroner ruled that there was insufficient evidence and it would be unsafe, as per the Galbraith plus principle, to allow the jury to make findings that the police knew or ought to have known about the attack and, as a result, failed to take steps to prevent the attack from happening.

The family sought judicial review of that decision given Article 2 was engaged. The Court agreed the Coroner’s approach was sound, emphasising that even when Article 2 applies, the jury should not be asked to make Article 2 related findings unless supported by adequate evidence.

This article was drafted by Alice Eckley, Jordan Coulton and Charlotte Whitaker. 

Please do not hesitate to get in touch with the team should you wish to discuss any inquest matters further. 

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