High Court Upholds Coroner’s Gatekeeping Role
R (Rizvi) v HM Assistant Coroner for South London [2025] EWHC 3014 (Admin)
Court: High Court (Administrative Court)
Judge: Foxton J
Date: 17 November 2025
In R (Rizvi) v HM Assistant Coroner for South London [2025] EWHC 3014 (Admin), the Administrative Court has provided a useful reminder of the limits of Article 2 at inquests, and the important gatekeeping role played by coroners.
Although the inquest into the death of Sabina Rizvi proceeded on an Article 2 basis, the High Court upheld the coroner’s decision that it would be unsafe to leave any findings of police failings to the jury.
The case illustrates a point frequently misunderstood in Article 2 inquests: the threshold for investigating a possible breach is low, but the threshold for leaving allegations of breach to the jury is considerably higher once the evidence has been heard.
The Background
In the early hours of 20 March 2003, Sabina Rizvi was shot dead as she drove away from Bexleyheath Police Station. Her boyfriend, Mark Williams, was a passenger in the car and was also shot. He survived but suffered a serious brain injury.
The gunman, Paul Asbury, was later convicted of Ms Rizvi’s murder and the attempted murder of Mr Williams. The individuals who carried out the shooting at his direction have never been identified.
The central issue explored at the inquest was whether police actions shortly before the shooting may have exposed Ms Rizvi to risk, particularly decisions taken by officers after Mr Williams had been interviewed at the police station.
The Article 2 Framework
The inquest proceeded on an Article 2 basis, meaning the investigation examined whether the police may have breached the operational duty to protect life.
Foxton J restated the well-known test derived from Osman v United Kingdom (1998) 29 EHRR 245. The operational duty arises where:
“the authorities knew or ought to have known at the time of the existence of a real and immediate risk to the life of an identified individual or individuals from the criminal acts of a third party and … failed to take measures within the scope of their powers which, judged reasonably, might have been expected to avoid that risk.” (§17)
The key question therefore became whether there was evidence capable of establishing that the police knew or ought to have known of a real and immediate risk to Ms Rizvi’s life.
The Coroner’s Ruling
After hearing the evidence, the Assistant Coroner ruled that no issues relating to a breach of the Article 2 operational duty should be left to the jury for their consideration.
Although the inquest had properly explored the circumstances of the death, the coroner concluded that the evidential threshold required for jury findings on police failings had not been met.
The coroner therefore declined to leave questions relating to alleged police breaches of Article 2.
The Judicial Review Challenge
Ms Rizvi’s mother brought judicial review proceedings arguing that the coroner had misdirected herself in law when deciding whether these issues should be left to the jury.
The claimant contended that there was sufficient evidence to allow a jury to conclude that the police had breached their operational duty.
However, the High Court emphasised that the relevant question for the coroner was whether there was evidence upon which a jury could properly (i.e safely) reach such a finding.
At §25 of his judgment, Foxton J relied on R (Secretary of State for Justice) v HM Deputy Coroner for the Eastern District of West Yorkshire [2012] EWHC 1634 which records at §20-§23:
It is clear, therefore, that when coroners are deciding whether or not to leave a particular verdict to a jury, they should apply a dual test comprising both limbs or ‘schools of thought’, i.e. coroners should (a) ask the classic pure Galbraith question “Is there evidence on which a jury properly directed could properly convict etc.?” (see above) plus (b) also ask the question “Would it be safe for the jury to convict on the evidence before it?“.
The second limb, arguably, provides a wider and more subjective filter than the first in certain cases. In my view, this extra layer of protection makes sense in the context of a coronial inquiry where the process is inquisitorial rather than adversarial, the rights of interested parties to engage in the proceedings are necessarily curtailed and coronial verdicts are at large.”
This reflects the Galbraith-style evidential threshold applied by coroners when deciding whether matters should be left to a jury.
The High Court’s Decision
The Judicial Review claim was dismissed. The original decision stood.
Foxton J held that the coroner had applied the correct legal approach and had been entitled to conclude that the evidential threshold was not met.
Importantly, the court stressed the limited role of judicial review in this context. The High Court does not act as an appellate body reviewing a coroner’s evaluation of evidence.
The challenge therefore required the claimant to demonstrate that the decision was irrational in the Wednesbury sense. This is a high bar to clear.
The judge rejected that submission in memorable terms:
“Mr Stanbury’s island-hopping expedition in a sea of extensive evidence did not persuade me that it was arguable that this was one of the very rare cases in which an experienced coroner’s assessment of the effect of evidence was unreasonable in the Wednesbury sense.” (§89)
The court concluded that the coroner’s decision was plainly within the range of reasonable conclusions open to her.
Article 2 Investigations vs Article 2 Findings
One of the most important lessons from the case is the distinction between:
- The procedural obligation to investigate under Article, and
- The substantive question of whether the state actually breached Article 2.
The threshold for triggering the procedural duty to investigate is relatively low.
However, once the evidence has been explored, it may still be appropriate for the coroner to conclude that no arguable state failure should be left to the jury.
In practice, this means that an Article 2 inquest does not guarantee that Article 2 findings will form part of the final conclusion.
I have written an explanation of how Article 2 operates.
The Coroner’s Gatekeeping Role
The judgment also reinforces the important gatekeeping role that coroners play for juries.
Coroners must ensure that only issues supported by sufficient evidence are left to a jury. This protects the integrity of the process and prevents juries from being asked to speculate about matters not properly supported by the evidence.
For families and practitioners alike, it is therefore essential to distinguish between:
- Matters which can properly be investigated, and
- Matters which the evidence is capable of proving.
Why the Decision Matters
For practitioners involved in Article 2 inquests, the judgment highlights three practical points.
1. Article 2 investigations are not outcome driven
An Article 2 inquest ensures that potential state failings are explored. It does not guarantee that the jury will ultimately consider actual allegations of breach – much less that they will find such breaches.
2. Coroners control what goes to the jury
Coroners must decide whether there is sufficient evidence to justify jury consideration of alleged state failures.
3. Judicial review will rarely succeed
Challenges to these rulings face a very high threshold, because the court will intervene only where the coroner’s decision is legally flawed – or irrational to such an extent no reasonable coroner could have made that decision.
Key Takeaways
- The threshold for triggering an Article 2 investigation is relatively low.
- The threshold for leaving allegations of state breach to a jury is significantly higher.
- Coroners act as gatekeepers, ensuring only properly supported decisions and issues can be left for the jury to consider.
- Judicial review of those decisions will succeed only in exceptional circumstances.