Bhupinder Iffat Rizvi, R (on the application of) v HM Assistant Coroner for South London

Mr Justice Foxton: Introduction

1. In the early hours of 20 March 2003, Sabina Rizvi was shot dead as she drove away from Bexleyheath Police Station. Her boyfriend, and a passenger in her car, Mark Williams was also shot. He survived, but sustained a significant brain injury. Paul Asbury has subsequently been convicted of the murder of Sabina Rizvi and the attempted murder of Mark Williams. The assailants who carried out the murder and attempted murder at Paul Asbury’s direction have never been identified, and have yet to face justice.

2. An inquest into Sabina Rizvi’s death (“the Inquest”) was opened on 25 March 2003, but adjourned pending Paul Asbury’s trial. After Paul Asbury’s conviction, the decision was initially taken not to resume the Inquest, but this was reversed thanks to the concerted efforts of the Rizvi family.

3. On 12 February 2019, the Senior Coroner for South London concluded that Article 2 of the European Convention on Human Rights (“ECHR”) was arguably engaged and that the Inquest should be resumed. Senior Coroner for South London’s appointed HHJ Angela Rafferty KC (“the Coroner”) to hear the case, with the Inquest taking place between 4 and 26 March 2024 before a coroner’s jury (“the Jury”). The Coroner is a highly experienced criminal judge who is a Senior Circuit Judge at the Central Criminal Court.

4. The period between the Senior Coroner for South London’s decision in February 2019 and the commencement of the Inquest was the result of a number of evidential, procedural and administrative complexities, with the result that the Inquest did not begin until 2024.

5. One issue which was raised at the Inquest was whether the First Interested Party (hereafter “the Police”) had breached the duty owed to Sabina Rizvi under Article 2 of the ECHR, namely the right to life. The issue was whether the Police (and in particular, the Second and Third Interested Parties, Roberto Florio and Thomas Horner), either did appreciate or should have appreciated that Paul Asbury posed a real and immediate threat to Sabina Rizvi’s life once she left the police station, and should have taken steps to mitigate that risk.

6. At the conclusion of the evidence on 24 March 2024, the Coroner gave a ruling (“the Ruling”) that there was sufficient evidence to establish that there was such a real and immediate threat, but insufficient evidence to leave to the Jury the issue of whether such a risk was or ought to have been known to the Police. The Coroner also found that there was insufficient evidence that there were steps which the Police could reasonably have been expected to take to prevent any risk to Sabina Rizvi materialising. As a result of that ruling, no issue as to the acts or omissions on the part of the Police was left to the Jury.

7. By this application, Sabina Rizvi’s mother, Bhupinder Iffat Rizvi (“Mrs Rizvi”) seeks permission to challenge the lawfulness of the Coroner’s ruling as a matter of public law, by way of proceedings for judicial review. Mrs Rizvi contends that the Ruling involved two errors of public law: i) “The Coroner erred in law by determining the matters to be left to the jury based upon whether there was sufficient evidence that the substantive Article 2 ECHR duty had been breached rather than whether such a breach was arguable, and added an unnecessary and impermissible gloss to the threshold for assessing whether such a breach had occurred (or was arguable).” ii) “The Coroner erred in law by eliding the question of whether there had been a breach of the substantive Article 2 duty with that of whether there was sufficient evidence that there were any acts or omissions by the police that were potentially causative of Sabina’s death which could safely be left to the jury”.

8. In order to bring such a claim, Mrs Rizvi must not only establish an arguable case of public law illegality, but she must also obtain an extension of time for bringing the claim. This is because, absent such an extension, applications for permission to bring proceedings by way of judicial review must be brought “promptly; and in any event not later than 3 months after the grounds to make the claim first arose” (CPR r 54.5(1)). In this case, Mrs Rizvi asks the court to extend time from 30 June 2024 to 24 September 2024.

9. While the claim is brought against the Coroner as defendant, the Police, Roberto Florio and Thomas Horner have been joined to the claim (“the Interested Parties”). The Coroner and the Interested Parties oppose Mrs Rizvi’s application for an extension of time and for permission to seek judicial review.

10. The judgment addresses the issues which arise under the following headings: i) The legal context to the Inquest. ii) The course of the Inquest. iii) The Ruling. iv) The extension of time application. v) Ground 1. vi) Ground 2. The legal context to the Inquest The role of the inquest

11. Under s.1 of the Coroners and Justice Act 2009 (“ the 2009 Act ”), a senior coroner who is made aware that the body of a deceased person is within their area must conduct an investigation into their death in certain circumstances, including where the coroner “has reason to suspect that the deceased died a violent or unknown death”.

12. Section 5 of the 2009 Act provides: “(1) The purpose of an investigation under this Part into a person's death is to ascertain— (a) who the deceased was; (b) how, when and where the deceased came by his or her death; (c) the particulars (if any) required by the 1953 Act to be registered concerning the death. (2) Where necessary in order to avoid a breach of any Convention rights (within the meaning of the Human Rights Act 1998 (c. 42)), the purpose mentioned in sub section (1 )(b) is to be read as including the purpose of ascertaining in what circumstances the deceased came by his or her death. (3) Neither the senior coroner conducting an investigation under this Part into a person's death nor the jury (if there is one) may express any opinion on any matter other than— (a) the questions mentioned in sub section (1 )(a) and (b) (read with subsection (2) where applicable); (b) the particulars mentioned in sub section (1 )(c).”

13. In determining whether s.5(2) (and the wider investigatory function of a coroner’s inquest it involves) is engaged, it is sufficient that there is arguably a breach of an Article 2 right. In R (Skelton) v HM Senior Coroner for West Sussex [2020] EWC 2813 (Admin), [16], a Divisional Court (Popplewell LJ and Jay J) stated: “The threshold for the procedural obligation to arise is that there has been an arguable breach of an article 2 substantive obligation. This threshold is a low one because to impose a more onerous burden would run the risk of the coroner determining, in advance of the full evidential picture, what the outcome of any inquest might be. “Arguable” in this context means anything more than fanciful (see R (Palmer) v HM Coroner for Worcestershire [2011] Inquest LR 50 , per Hickinbottom J, at para 60). The threshold was expressed in slightly different language by Lord Burnett of Maldon CJ in R (Maguire) v Blackpool and Fylde Senior Coroner where he said: “the procedural obligation imposed by article 2 … with which we are concerned [is] the parasitic procedural obligation to investigate when a credible suggestion is made that the state has breached its substantive article 2 obligations.”” [2021] QB 409 , para 75

14. Finally, s.10 of the 2009 Act provides: “(1) After considering the evidence given to an inquest into a death, the senior coroner (if there is no jury) or the jury (if there is one) must— (a) make a determination as to the questions mentioned in section 5(1) (a) and (b) (read with section 5(2) where applicable), and (b) if particulars are required by the 1953 Act to be registered concerning the death, make a finding as to those particulars. (2) A determination under sub section (1 )(a) may not be framed in such a way as to appear to determine any question of— (a) criminal liability on the part of a named person, or (b) civil liability. (3) In subsection (2) “ criminal liability ” includes liability in respect of a service offence.” Article 2 inquests

15. The ECHR right which arises in this context is Article 2: “Everyone’s right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which the penalty is provided by law”. Inquests in which Article 2 issues arise are understandably referred to as “Article 2 inquests”. Inquests which do not engage the wider enquiry contemplated by s.5(2) of the 2009 Act are frequently referred to as Jamieson inquests (after R (HM Coroner for North Humberside and Scunthorpe) ex parte Jamieson [1995] QB 1 ).

16. Article 2 has a number of elements, which are discussed in R (Skelton) v West Sussex Senior Coroner [2020] EWHC 2813 (Admin) , [50]-[63]. For present purposes it is sufficient to distinguish: i) Its procedural element: this imposes a duty of enhanced investigation, to initiate an effective public investigation by an independent official body into any death occurring in circumstances in which it appears that a substantive obligation has been or may have been violated, and it appears that agents of the state are, or may be, implicated in some way. That duty is addressed in s.5(2) of the 2009 Act . ii) Its substantive element: the substantive duty to protect life, which includes an obligation on the state to establish a framework of laws, precautions, procedures and means of enforcement which will to the greatest extent reasonably practicable do so but also in certain circumstances an operational duty to take positive preventative measures to protect life.

17. The content of that substantive duty in the present context was established by the European Court of Human Rights in Osman v United Kingdom (1998) 29 EHRR 245 , [116]: “It must be established to its satisfaction that 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 that they failed to take measures within the scope of their powers which, judged reasonably, might have been expected to avoid that risk.”

18. It will be noted that there are the following elements to the Article 2 breach Osman formulates: i) 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.” ii) That they “failed to take measures within the scope of their powers which, judged reasonably, might have been expected to avoid that risk.” The roles of the Coroner and the Jury

19. Where s.7(2) or (3) of the 2009 Act apply, the inquest is to be held with a jury. One of those circumstances is where “the senior coroner has reason to suspect … that the death resulted from an act or omission of a police officer or a member of a service police force in the purported execution of the officer’s or member’s duty as such”.

20. The provisions of the 2009 Act are supplemented by the Coroners (Inquests) Rules 2013 (SI No 1616 of 2013), Rule 33 of which provides: “Where the coroner sits with a jury, the coroner must direct the jury as to the law and provide the jury with a summary of the evidence.”

21. There are obvious superficial similarities between those assigned roles, and those of a judge and jury in a criminal trial. However, as Fordham J noted in R (Glaister and others) v HM Assistant Coroner for North Wales [2025] EWHC 167 (Admin) , [13]: “There are fundamental differences between coroner’s inquests and crown court trials. Coroners are a type of court; with a jury; with legal directions; and a summing up. Some ‘criminal law concepts’ are ‘applied’ … There are Galbraith rulings about what can be left. But there are very important differences” (a number of which he then identified).

22. It is the application of the Galbraith test in an inquest which lies at the heart of this application. In a criminal trial, the defendant can make submissions at the close of the prosecution case to the effect that they have “no case to answer”, and that a not guilty verdict should be entered without the need for the defendant to open and advance their case. Clearly applications of this kind bring into sharp focus the different roles of judge and jury in a criminal case, and in particular the fact that, as juries are invariably informed by judges at the start of any criminal trial: “I am responsible for legal matters, and will tell you about the law which applies to this case. You must accept and apply what I tell you about the law. You are responsible for weighing up the evidence and deciding the facts of the case. It is entirely up to you to decide what evidence is reliable and what evidence is not.” (Crown Court Compendium Part 1 –October 2025, page 4-3).

23. The manner in which those different functions are respected when the Judge is asked to dismiss a count, and withdraw it from the jury on the basis that there is no case to answer was settled in R v Galbraith [1981] 1 WLR 1039 . At p.1040, Lord Lane CJ referred to there being: “two schools of thought: (1) that the judge should stop the case if, in his view, it would be unsafe (alternatively unsafe or unsatisfactory) for the jury to convict; (2) that he should do so only if there is no evidence upon which a jury properly directed could properly convict. Although in many cases the question is one of semantics, and though in many cases each test would produce the same result, this is not necessarily so. A balance has to be struck between on the one hand a usurpation by the judge of the jury's functions and on the other the danger of an unjust conviction.”

24. At p.1042, Lord Lane CJ resolved that controversy in criminal cases by approving the following test: “(1) If there is no evidence that the crime alleged has been committed by the defendant, there is no difficulty. The judge will of course stop the case. (2) The difficulty arises where there is some evidence but it is of a tenuous character, for example because of inherent weakness or vagueness or because it is inconsistent with other evidence. (a) Where the judge comes to the conclusion that the prosecution evidence, taken at its highest, is such that a jury properly directed could not properly convict upon it, it is his duty, upon a submission being made, to stop the case. (b) Where however the prosecution evidence is such that its strength or weakness depends on the view to be taken of a witness's reliability, or other matters which are generally speaking within the province of the jury and where on one possible view of the facts there is evidence upon which a jury could properly come to the conclusion that the defendant is guilty, then the judge should allow the matter to be tried by the jury. It follows that we think the second of the two schools of thought is to be preferred.”

25. In the context of a coroner’s inquest, the test which a coroner should apply before leaving an issue to the jury has been the subject of some debate. The history of this issue is traced in the judgment of a Divisional Court (Stuart-Smith LJ and Fordham J) in R (Police Officer B50) v HM Assistant Coroner for the East Riding of Yorkshire and Kingston upon Hull [2023] EWHC 81 (Admin) . In brief: i) In R v HM Coroner for Exeter and East Devon ex parte Palmer [2000] Inquest Law Reports 78, the Court of Appeal considered the application of the Galbraith test in the context of a public law challenge, on Wednesbury grounds, to a coroner’s decision to leave an issue to the jury. The language used by Lord Woolf in [46] and [49] of the judgment has been treated in subsequent cases as involving a gloss on the Galbraith test in the context of a coroner’s inquest, although the Divisional Court in B50 doubted that this interpretation follows from the decision. ii) In R v Inner South London Coroner ex parte Douglas-Williams [1999] 1 All ER 344 , Lord Woolf MR at 348-49 expressly supported a wider “gate-keeping” role for a coroner sitting with a jury than a criminal judge at a jury trial, given the different nature of the two proceedings. He stated that a coroner had a discretion not to leave an issue to the jury where the coroner “acting reasonably and faithfully” concludes that “it is not in the interests of justice that a particular verdict should be left to the jury”. It was sufficient, he said, to “leave those verdicts which realistically reflect the thrust of the evidence as a whole”. That formulation was justified by what might be described as “jury management” considerations – the risk of overwhelming a jury (cf. the reference to similar considerations in the context of “overloaded” indictments in criminal trials: Crown Court Compendium Part 1 page 6-6). iii) Later cases, however, suggested that the application of the Galbraith test in the context of a coroner’s jury might involve a different test for withdrawing issues from the jury by reference to the strength of the evidence. B50 traces the course of the authorities, identifying R (Bennett) v HM Coroner for Inner South London [2007] EWCA Civ 61 , [27] as the first case clearly to this effect. iv) In R (Secretary of State for Justice) v HM Deputy Coroner for the Eastern District of West Yorkshire [2012] EWHC 1634, [20]-[23], Haddon-Cave J formulated the position as follows: “ Galbraith ‘plus' The authorities recognise that there is some (if small) distinction between the position of a coroner deciding what verdict to leave to a jury after hearing all the evidence and that of a judge in a criminal trial considering whether to stop a case after the conclusion of the prosecution case. This was made clear by Waller LJ in R (Bennett v HM Coroner for Inner South London ). Waller LJ cited passages of Lord Woolf MR in [2007] EWCA Civ 61 7 R v HM Coroner for Exeter, Ex Parte Palmer [1997] CA (10 December) and Leveson J in Sharman v. HM Coroner for Inner North London [2005] EWHC 857 (Admin) … Waller LJ went on to note that the very issue in Galbraith was which of the ‘two schools of thought’ was to be preferred. Waller LJ held on the facts of that case that the coroner was right to take the view that a verdict of unlawful killing could not be safely left to the jury in that case (see paragraph [34]). 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.” v) That “ Galbraith -plus” formulation was endorsed by Sir Brian Leveson P in R (Tainton) v HM Senior Coroner for Preston and West Lancashire [2016] EWHC 1396 (Admin) , [39] and R (Wandsworth BC) v Her Majesty’s Senior Coroner for Inner West London [2021] EWHC 801 (Admin) , [31]. vi) In B50 , the Divisional Court held that the added element to the Galbraith test in the coroner’s jury context was established by authority binding on them, while expressing some doubts both as to the necessity for such a distinction, and the manner in which it had been formulated ([64]-[65]). Challenges to a coroner’s Galbraith decision

26. In a conventional appeal to the Court of Appeal Criminal Division against a decision by a trial judge to terminate a case because there is no case to answer, the Court of Appeal adopts the approach in R v B [2008] EWCA Crim 1144 , [19]: “When the judge has exercised his discretion or made his judgment for the purposes of and in the course of a criminal trial, the very fact that he has had carefully to balance conflicting considerations will almost inevitably mean that he might reasonably have reached a different, or the opposite conclusion to the one he did reach. Leave to appeal … will not be given by this court unless it is seriously arguable, not that the discretionary jurisdiction might have been exercised differently, but that it was unreasonable for it to have been exercised in the way that it was.”

27. Where, however, a challenge is brought in public law to the decision of a coroner to leave or not to leave an issue to the coroner’s jury, the burden faced by the party bringing that challenge is altogether higher. The basis on which such a decision can be challenged is summarised in R v HM Corner for Exeter and East Devon ex parte Palmer [2000] Inquest LR 78: “The first is whether there is a mistake of law. If the deciding body has made a mistake of law, then the courts can intervene to correct that mistake. Second, they can intervene if the body making the decision has failed to take into account a consideration which they are required to take into account, or has taken into account a consideration which they are not entitled to take into account. Thirdly, applying the test to a Coroner, the courts can do so where a Coroner has acted in such a way which no reasonable Coroner would act, having properly directed himself as to the law. … [T]he Coroner has to make decisions where he has a broad discretion. Where he has a discretion, then the court … should not intervene except on Wednesbury grounds. We have no jurisdiction to act as a Court of Appeal in relation to decisions of Coroners.”

28. The application of conventional public law principles to this latter question is confirmed by R (Glaister and Carr) v His Majesty’s Assistant Coroner for North Wales (East and Central) [2025] EWHC 167 (Admin) , [27] and [55]. 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: i) 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: i) 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: i) 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: a) Whether the Police deliberately notified Paul Asbury and/or others of the whereabouts of Mark Williams. b) Whether the Police inadvertently notified Paul Asbury and/or others of the whereabouts of Mark Williams. c) 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: a) 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. b) Whether the Police knew that the risk arose from the criminal acts of Paul Asbury and his associates. c) Whether the Police failed to take measures within the scope of their powers which, judged reasonably, might have been expected to avoid that risk. v) 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”: a) There was a risk to the life of Ms Rizvi. b) 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). c) The risk came from Paul Asbury and his associates. d) The police were or ought to have been aware of (a) to (c). e) There were steps that the police could reasonably have been expected to take to prevent the risk from materialising. f) 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: i) “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: i) 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: i) 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”. v) 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. The Ruling

42. The Coroner prepared a written ruling which she began delivering at 4pm on 25 March. In the summary which follows, I have given paragraph references to the written Ruling.

43. The Coroner summarised the relevant provisions of s.5 of the 2009 Act [4], and she referred to the judgments of Haddon-Cave J in the Eastern District of West Yorkshire case and of the Divisional Court in B50 when setting out the test she intended to apply ([6]-[7]). Having referred to the Galbraith - Gailbraith plus debate, the Coroner said that she intended to apply Lord Lane CJ’s test in Galbraith itself ([8]), stating: “I am aware that Galbraith Plus can be applicable to the coronial jurisdiction, but the application of the Galbraith Plus test will rarely lead to a different outcome to that of classic Galbraith analysis”.

44. The Coroner also set out the test in Osman , [116], to which all parties in the Inquest had referred throughout ([9]). She then stated ([12]): “Three key issues were identified as being within the scope of this inquest. Firstly, whether the Metropolitan Police Service deliberately notified Paul Asbury and/or others of the whereabouts of Mark Williams. Secondly, whether the Metropolitan Police Service inadvertently notified Paul Asbury and/or others of the whereabouts of Mark Williams. Whether the Metropolitan Police Service 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”.

45. The Coroner dealt with the first two issues relatively briefly, holding that, applying the conventional Galbraith test, the first two issues could not properly be put to the Jury ([14]-[17]). There is no challenge to that part of her ruling.

46. The third was dealt with at much greater length. I do not propose to set out the Coroner’s consideration of the issue in full, but to identify only those parts of the ruling relevant to the test she applied, or to demonstrate the conclusion reached: i) The Coroner noted that “my role is to apply the law to the facts of this inquest, and to rule whether there is sufficiency of evidence to leave anything other than a short form conclusion to the jury” ([24]). ii) The Coroner addressed the evidence under six headings which had featured in CTI’s submissions (see [37(vi)] above), being the six issues which, if the evidential threshold was met, would be left to the Jury for narrative verdicts. iii) There was clearly “a risk to the life of Sabina Rizvi”, and that sufficiency of evidence was established on that issue ([28]). iv) There was “sufficient evidence that there existed in reality a real and immediate risk to the life of Sabina Rizvi” and that this risk came from Paul Asbury and his associates ([29]-[30]). v) There was “insufficient evidence on which a jury could properly find that it was risk of which any police officer was or should have been aware” ([45]). vi) If there was no risk “of which any officers were or ought to have been aware, then there is no basis on which the jury properly directed could properly find that there were steps the police should have taken to protect Sabina” ([46]). vii) The evidence that the police offered Mark Williams a life in an unmarked car, and extended that offer to Sabina Rizvi, did not “provide enough to engage Article 2 ” ([48]). viii) A jury properly directed could not regard the involvement of SO19, the Police specialist firearms unit, as “a reasonable step that ought to have been taken in this matter given the resources involved” ([52]). ix) “It would not be open to a jury to conclude that a risk assessment ought to have taken place” ([52]). x) “The evidence I have heard at this inquest is insufficient such that a properly directed jury could find that the police were or ought to have been aware of any immediate risk to Sabina Rizvi’s life from Paul Asbury, and there is insufficient evidence to support the suggestion that that the police were or ought to have been aware of such a risk from any quarter” ([55]). xi) “There is insufficient evidence that there were steps the police could reasonably have been expected to take to prevent any risk to Sabina from materialising, and therefore there is no evidence that the police failed to take such steps” ([56]). xii) “I do not in these circumstances consider it necessary or appropriate to make findings as to causation” ([56]).

47. At that point the Coroner gave the represented parties an opportunity to consider her Ruling (it being 16.50pm when the reading of the Ruling finished).

48. Mrs Rizvi sought advice from the counsel team representing the family at the Inquest on the prospects of bringing a judicial review challenge to the Ruling and the advice was negative.

49. On 26 March, Mrs Rizvi’s counsel team applied to adjourn the Inquest for two to three weeks, putting jury deliberations on hold in the interim, to allow the family to obtain a second opinion. The Coroner refused the application.

50. That day, the Jury returned a short-form verdict of unlawful killing. The application for an extension of time The chronology

51. The unsuccessful application for an adjournment on 26 March 2024 was the last the Coroner or the Interested Parties heard about a proposed judicial review application until the present application was served on them on 4 October 2024.

52. The evidence indicates that on 23 April 2024, Mrs Rizvi obtained advice from counsel who was not a member of the Inquest team, the precise terms of which are not known. Her evidence is that a conflict of interest on the part of the lawyer concerned became apparent at the beginning of May 2024. At that point, efforts to instruct lawyers appear to have ceased, for the time being, with Mrs Rizvi seeking to prepare a judicial review challenge herself.

53. On 17 June 2024, Mrs Rizvi emailed the Administrative Court Office (“ACO”) with a Claim Form N461, Statement of Facts and Grounds and Fee Remission Form. The Statement of Facts and Grounds advanced five grounds, none of them the two now advanced: i) The decision had failed to take account of relevant material, and was Wednesbury unreasonable for that reason. ii) The Ruling was Wednesbury unreasonable in its result. iii) The Coroner had taken account of irrelevant considerations. iv) The Coroner had breached Sabina Rizvi’s Human Rights by “stereotyping” her. v) The Coroner had failed to have regard to the fact that Mark Williams was permitted to make unsupervised calls from the police station, contrary to policy.

54. Mrs Rizvi’s email stated that various documents would be provided to the ACO within 4 to 5 weeks including the Ruling. No copy of the claim form was provided to the Coroner or any of the interested parties.

55. On 19 June 2024, the ACO sent Mrs Rizvi the Help With Fees application form. However, on the date, the ACO informed Mrs Rizvi that: “We would not be able to process the [HWF] application as the applicant is in receipt of a legal aid certificate” (a reference to the legal aid certificate granted to the Rizvi family for the Inquest).

56. Mrs Rizvi’s evidence is that, at this stage, she thought it was an issue relating to payment of the fee which was preventing her judicial review application being processed. However, on 24 June 2024 the ACO wrote stating that the court needed a copy of the decision she was seeking to challenge.

57. On 10 July 2024, Mrs Rizvi responded to the ACO letter regarding Help With Fees stating that the legal aid certificate granted for the Inquest did not extend to the judicial review application. She provided a copy of the Ruling at the same time, although this does not appear to have been appreciated at the ACO, who stated in an email of 16 July 2024 that the claim form could not be issued until it had been received.

58. At some point after 16 July 2024, Mrs Rizvi made contact with the chambers of her current counsel, Matthew Stanbury, to be told that counsel was away from 22 July to 19 August. No other counsel appears to have been approached, but a conference with Mr Stanbury was fixed for 20 August 2024. By the end of August 2024, Mrs Rizvi was in contact with her current solicitors, who had a meeting with Mrs Rizvi on 28 August 2024, and set about assembling the documents required for a legal aid application. Initially, the solicitors thought that Mrs Rizvi would not be eligible for legal aid, but further information was forthcoming. On 5 September 2024, the solicitors accepted instructions and the following day a legal aid application was submitted (with emergency legal aid being granted on 20 September 2024).

59. A draft statement of facts and grounds was circulated on 19 September 2024, and approved on 23 September. The documents were sent to the Administrative Court on 24 September. The applicable legal principles

60. CPR 54.5(1) provides that “the claim form must be filed (a) promptly; and (b) in any event not later than three months after the ground to make the claim first arose.”

61. Section 31(6) Senior Courts Act 1981 provides: “Where the High Court considers that there has been undue delay in making an application for judicial review, the court may refuse to grant (a) leave for the making of the application ... if it considers that the granting of the relief sought would be likely to cause substantial hardship, or substantially prejudice the rights of any person or would be detrimental to good administration.”

62. The Court can extend the three-month time limit. Paragraph 6.4.4.2 of The Administrative Court Guide 2025 states: “In considering whether to grant an extension of time, the Court must first determine the date from which the relevant time period started to run so that the period of delay can be calculated correctly. The Court will then consider all the circumstances, including whether an adequate explanation has been given for the delay, the importance of the issues, the prospects of success and whether an extension will cause substantial hardship or prejudice to the defendant or any other party or be detrimental to good administration.”

63. The Guide refers to Maharaj v National Energy Corporation of Trinidad and Tobago [2019] 1 WLR 983 , [38] in which Lord Lloyd-Jones stated: “Here it is important to emphasise that the statutory test is not one of good reason for delay but the broader test of good reason for extending time. This will be likely to bring in many considerations beyond those relevant to an objectively good reason for the delay, including the importance of the issues, the prospect of success, the presence or absence of prejudice or detriment to good administration, and the public interest.”

64. At [47], he continued: “While prejudice or detriment will normally be important considerations in deciding whether to extend time, there will undoubtedly be circumstances in which leave may properly be refused despite their absence. One example might be where a long delay was wholly lacking in excuse and the claim was a very poor and inconsequential one on the merits, such that there was no good reason to grant an extension”.

65. In Fishermen and Friends of the Sea v Environmental Management Authority [2018] UKPC 24 , [22] the Board noted that “the purpose of that specific limit is to provide a degree of certainty to those affected, and accordingly … strong reasons are needed to justify extending it where other interests, public or private, are involved”.

66. Delay in obtaining legal aid is not normally a sufficient factor to persuade a court to grant an extension of time ( R (Kigen) v SSHD [2015] EWCA Civ 1286 , [18]) although “it may still be a factor which can be taken into account”. Analysis and conclusion Should the claim be treated as effectively in time?

67. I should deal first with the suggestion made on Mrs Rizvi’s behalf that the submission of the 17 June 2024 claim form to the ACO should be treated as the bringing of a claim in time, or something close to it, by analogy with CPR 7.2 and Practice Direction 7A para. 6.1 and 6.2: i) Rule 7.2 provides that proceedings are started when the court issues a claim form at the request of the claimant. ii) Practice Direction 7A para. 6.1 provides that “where the claim form as issued was received in the court office on a date earlier than the date on which it was issued by the court, the claim is ‘brought’ for the purposes of the Limitation Act 1980 and any other relevant statue on that earlier date.”

68. I am not persuaded that these provisions assist Mrs Rizvi: i) First, the claim for judicial review for which permission is sought is not in the terms of the claim form submitted to the Administrative Office on 17 June 2024, but materially different. ii) Second, the provisions in question are not directly applicable to claims for judicial review, and are not concerned with a case, such as the present, in which the court requires further information from the claimant before it can issue the claim form. Is there a reasonable excuse for the delay?

69. There are a number of periods of delay which, judged by the ordinary standards of public law proceedings, involve unreasonable delay: i) First, there is a period of unexplained delay (within the three-month period, but not consistent with the obligation to act promptly) between 26 March 2024, when the family’s application to adjourn the Inquest so that a second opinion might be obtained failed, and 23 April 2024, when advice was obtained from another counsel. The court has been told relatively little about this period. ii) Second, there was a period of unexplained delay (albeit again within the three-month period, but not consistent with the obligation to act promptly) between the start of May (when the issue of conflict of interest is said to have arisen, albeit in unexplained circumstances) and the sending of the claim form to the ACO on 17 June 2024. iii) Third, there is a period of delay (largely after the three-month period had expired) between 24 June 2024, when the ACO asked for a copy of the decision being challenged, and 10 July 2024, when it was provided. Indeed it is not clear why no copy could be provided on 17 June 2024. iv) Against the background of the three-month time limit expiring on 24 June 2024, the delay in instructing counsel until after 16 July 2024, and then instructing counsel who was not available for a conference until 20 August 2024, involved insufficient expedition. v) The time taken between that conference on 20 August 2024 and the sending of the statement of facts and grounds to the ACO on 24 September also manifested insufficient urgency, although I do take account as a factor explaining the time taken the application for legal aid. That application, however, (a) did not hold up the drafting of the statement of facts and grounds which was circulated before legal aid was granted; and (b) was processed relatively promptly, with an application made on 6 September 2024 resulting in the grant of emergency legal aid on 20 September 2024.

70. I should refer in this regard to evidence from Mrs Rizvi, which I accept, of the devastating effect her daughter’s tragic death has had and is continuing to have on her, and the difficulties she has had in progressing this application as a lay person. I have sought to make allowances for this, albeit delay occurred at key points in the process when lawyers were involved.

71. My overall conclusion is that there was some unreasonable delay in bringing the application, albeit not at the egregious end of the scale. The importance of the issues

72. I accept that the issues which Mrs Rizvi seeks to address through this application are matters of obvious importance, being concerned with the role of the Police in her daughter’s death. The prospects of success

73. I address the prospects of success in greater detail below. For present purposes, it is sufficient to note that this is an extremely challenging application, brought in circumstances in which the highly experienced legal team representing the family at the Inquest had advised that there was no arguable claim. The premise of the claim is that notwithstanding a detailed ruling reached after hearing full legal submissions from all interested parties, a highly experienced criminal judge either misunderstood the conventional Galbraith test of which she has had a lifetime’s professional experience, or that she misapplied it. Would an extension of time cause substantial hardship or prejudice to the defendant or any other party or be detrimental to good administration?

74. I have found this the most difficult factor to evaluate: i) As to prejudice, the evidence of the Coroner is that had the issue been raised more promptly, steps would have been taken to retain the Inquest papers or ensure the availability of the Coroner in any challenge. I was not persuaded, however, that there had been any irreversible prejudice in those two specific requests. ii) I accept for the Interested Parties, and particularly for the two individuals, the continuation of a matter which they thought had been resolved, will be a source of ongoing stress. However, the court cannot be blind to the ongoing torment to the family, at least one element of which arises from their sense that no coroner’s jury has pronounced on what they regard as the important issue of Police responsibility. iii) However, it is also important to note that Sabina Rizvi was tragically murdered in 2003. There was a lengthy inquest with a jury, with publicly funded representation for the interested parties, and which followed an extensive evidence-gathering exercise, in February and March 2024. The campaign of the Rizvi family has already achieved much, with the individuals involved in these events subject to searching cross-examination in a public forum by teams of skilled advocates. iv) The effect of extending time for Mrs Rizvi’s application will be to prolong the legal uncertainty with regard to these events. If the application were to succeed, the only viable form of relief would be to re-hold the Inquest. v) Factors (iii) and (iv) weigh strongly in favour of refusing the application for an extension of time. I accept that even if the application had been brought promptly, the effect of success would still have been further lengthy delay. Nonetheless, given the lapse of time since the tragic events which form the background to this application, it was obviously important to seek to move matters forward with the greatest possible expedition. That has not, I regret to say, been done. Conclusion

75. Taking all of these factors into account, I have decided to refuse Mrs Rizvi’s request for an extension of time. Mrs Rizvi’s Grounds Ground 1

76. Mrs Rizvi’s first ground is as follows: “The Coroner erred in law by determining the matters to be left to the jury according to whether there was sufficient evidence that the substantive Article 2 ECHR duty had been breached, rather than whether such a breach was arguable, and added an unnecessary and impermissible gloss to the threshold for assessing whether such a breach had occurred or was arguable”.

77. This ground was developed by reference to three complaints. Did the Coroner ask herself the right question?

78. First, that the Coroner asked herself “the wrong question” when stating: “The question is does any issue remain under Article 2 to leave to the jury to consider? All parties agree on the law which I must apply, with a difference of emphasis and at times interpretation. All parties agree on the test in Galbraith ”.

79. This was said not to be the correct test because “the question of whether the Article 2 duty is engaged arises quite separately from the question of whether there are issues which can properly and safely be left to the jury”. As the matter was developed in oral argument, Mr Stanbury sought to distinguish the legal issues relating to Article 2, which he said were not matters for the Jury, and the issue of evidential sufficiency. He suggested that the Coroner had been led into error by confusing these two separate matters.

80. I am satisfied that this ground is not arguable, and I suspect that, as a complaint, it would have come as something of a surprise to the family’s legal team at the Inquest: i) The relevant issue for the Coroner was whether, applying the relevant test, there was sufficient evidence for certain issues to be left to the Jury. Those issues were the factual issues which were relevant to a substantive Article 2 complaint. ii) As I have explained, the issue of potential Article 2 liability had been front and centre of the Inquest after it had been resumed following Paul Asbury’s conviction, and the focus of all parties after the completion of the evidence was whether issues of fact relevant to Article 2 liability should be left to the Jury and, if so, which. For that reason, all counsel (including counsel for the family) made submissions to the Coroner about the Osman test, and framed their argument in relation to the issues which should or should not be left to the Jury by reference to the factual predicates of Osman liability. No counsel (including counsel for the family) suggested that this was in any way inappropriate. iii) The Ruling addressed the various factual issues to which the various parties had drawn attention in the context of the Article 2 substantive duty, for the purpose of determining whether the evidential threshold for leaving the factual basis of Article 2 liability to the Jury was met. That did not involve (as Mr Stanbury at one point seemed to be suggesting) simply deciding if there was an arguable Article 2 claim. That was relevant to the issue of what type of inquest (Article 2 or Jamieson ) was required to discharge the procedural Article 2 duty, but by the end of the evidence, matters had moved beyond that issue. At this stage, the issue for the Coroner was not one of arguability, but of evidential sufficiency applying the Galbraith test. iv) The fact that coroner’s juries do not themselves determine civil liability ( s.10(2) of the Act ) does not, as Mr Stanbury submitted, have the effect that a coroner is only concerned with what is arguable when leaving issues to the Jury. The Jury is concerned with making factual findings on particular issues, not determinations of liability, albeit particular factual findings will obviously be relevant to certain forms of civil liability and, as in this case, the ingredients of particular forms of liability will have a very strong influence on those issues a coroner is asked to leave to the jury. Did the Coroner inappropriately gloss the test for an Article 2 operational breach?

81. The second complaint is that in the Ruling, the Coroner had mischaracterised the test for a substantive Article 2 breach when she stated that “in matters involving criminal acts of someone who is not a state agent the level of risk to cross the real and immediate threshold is very high”. As to this: i) I accept that in Van Colle v Chief Constable of Hertfordshire [2008] UKHL 50 , [30], Lord Bingham stated “I would for my part accept that a court should not lightly find that a public authority has violated one of an individual's fundamental rights or freedoms .. But I see force in the submission … that the test formulated by the Strasbourg court in Osman … is clear and calls for no judicial exegesis.” ii) However, the “real and immediate” risk threshold has frequently been recognised as “high” or “very high”: see e.g. Rabone v Pennine Care NHS Foundation Trust [2012] UKSC 2 , [36]; Van Colle v Chief Constable of Hertfordshire [2008] UKHL 50 , [30], [69], [115]; R (AP) v HM Coroner for Worcestershire [2011] EWHC 1453 (Admin) , [79]; R (Kent County Council)v HM Coroner for the County of Kent [2012] EWHC 2768 (Admin) , [43]; G4S Care and Justice Services Ltd v Kent County Council [2019] EWHC 1648 (QB) , [74]; R (Ferguson) v HM Assistance Coroner for Sefton, Knowsley and St Helens [2025] EWHC 1901 (Admin) , [24]; and Chief Constable of Sussex Police v XGY [2025] EWCA Civ 1230 , [83]. iii) More fundamentally, however, the Coroner was persuaded that a risk at the requisite level did exist. However, applying Galbraith , she found that there was “insufficient evidence on which a jury could properly find that it was a risk of which any police officer was or should have been aware.” iv) For those reasons, this point is not arguable and goes nowhere. The criticism of the Coroner’s findings as to the “off the record” conversation and the offer of a lift

82. Mr Stanbury took me to a limited number of passages in the evidence from the Inquest, for the purposes of challenging the Coroner’s assessment of the evidence, and to suggest that the Coroner had failed to distinguish between the proper provinces of the coroner and the jury. In particular, he made granular criticisms of the Coroner’s treatment in the course of the Ruling of two important pieces of evidence.

83. First, the “off the record” conversation between Mark Williams and Roberto Florio after Mark Williams’ “interview under caution” had ended. A near contemporaneous note of that conversation stated: “Paul ASBURY, [and others] run the drugs supply round this area. They are earning lots of money from it. Lee MURRAY is going away from it. He does more fighting now and is into property developing, as is Asbury. Asbury has an Uzi machine pistol. I don’t know where he keeps it. Obviously they are keeping it away from me, but I know he has this weapon and ammunition for it. He has a shotgun as well. I haven’t seen these weapons. I’m at war with gypsies, I’m having it with [a person he names] and them lot. These people all think they are gangsters. They don’t know who they’re dealing with. I run with Andy Wanogho (Sparks). He is on the run for murder. That’s why I wear a bullet−proof vest the whole time. I’ve got a [visiting order] for Dwayne Freeman who is doing a life sentence for a shooting in the West End. We will take over the drugs market here. You won’t get anywhere with this robbery. Asbury hasn’t been car−jacked he is talking crap. I have never done any knifepoint robbery. If I was to rob him I’d do it proper. Asbury has spoken to me on the telephone. I said I want £10,000 for the car for trying to knock my girl. He told me to forget the car and that I would never live to collect the money.”

84. I should briefly refer to submissions by Mr Gibbs KC that the accuracy and truthfulness of Mark Williams’ statements, with specific reference to the Uzi machine pistol, was seriously challenged by evidence before the Inquest. That reflects the fact that the Coroner will have heard evidence from a number of sources when reaching her assessment of evidential sufficiency, but it is not practical for the court on a permission application to seek to replicate that process, nor would it be appropriate.

85. For present purposes, it is sufficient to record the Coroner’s treatment of this issue: “[31(xix)] Asbury was a known thief, robber and burglar with no convictions for violence. DC Horner knew him for 10 years and did not consider him any risk to either Sabina or Williams. Horner knew him as an acquisitive offender and not violent or capable of murder. He was thought to be involved in drugs. The evidence I heard was that DS Florio considered him more “small time” that Williams. Mark Williams himself was scathing about Asbury and called him a “pussy”. Williams was a dangerous and violent career criminal and well aware of his status as such. He told the police that he intended to take over the drug dealing market in Asbury’s area. Williams said the bullet proof vest was being worn because of threats from others and he had been wearing it for three months. These others were significant criminals with whom he had disputes. He named them in the off the record account. The jury has a document prepared after the shooting by the officers containing the details of this conversation. [31(xx)] The police officers said that Williams gave the clear impression that he was not afraid of Asbury and that in fact he considered Asbury should be afraid of him in saying “they don’t know who they are dealing with”. The fact that Williams seemed to be able to persuade Asbury to drop the charges whilst in the police station was capable of signifying to the police that he had more criminal power. Asbury had on one view “grassed” Williams to the police. The police could therefore have considered MW to be the aggrieved party. [31(xxi)] It is clear from the off the record conversation that MW described a risk to his life that came from other people, not PA. This was the risk he seemed most concerned with and the reason he gave for wearing a bullet proof vest. [39] On the intelligence gisted to the inquest and available at the time, Asbury had not committed violent crimes with guns or weapons apart from when he was 13. He had been an acquisitive criminal since the age of 11 and was known to DC Horner as such. The off the record conversation between Williams and the two police officers did not raise a risk of a murderous attack outside the police station that night by Asbury. In fact both officers said that Williams was more concerned about serious threats from other criminals. He said that he was “at war with the gypsies”, who include PA and his associates. This was a war over drugs supply. He was clearly not afraid of this group. He said in fact that he intended to take over PA’s drug dealing patch and that PA was a “pussy”. Sabina was not mentioned in the off record briefing. [40] MW believed that the threat to him came from the enemies of W, who might attack him in revenge for a murder committed by W previously. He said this was why he was wearing the bullet proof vest which he had been wearing for 3 months.”

86. Second, evidence on the issue of whether Sabina Rivzi was offered a lift by the Police from the police station. As to this: i) At [31(xxvii)], the Coroner stated “the officers did offer a lift to MW in an unmarked car, an offer that extended to Sabina. DC Horner said it was because it was late, MW had been cooperative and this was something he often did.” ii) At [35], the Coroner recorded that CTI “points out that a lift was offered and this offer seems to have extended to Sabina. The reason DC Horner gave for offering a lift was the co-operation of MW, the lateness of the hour and it was essentially a courtesy. In any event, the offer was not taken up.”

87. I am not persuaded that there is any substantive difference between these two expressions, still less that it is arguable that the Coroner was “muddled” on a fair reading of the Ruling. The words “seems to have extended to Sabina” quoted the submissions CTI had made in the terms CTI had adopted. Mr Stanbury’s complaint at the hearing focussed on the Coroner’s account of the reasons why the lift had been offered.

88. It is clear from my review of their written and oral closing submissions that, as would be expected, all of the points made by Mr Stanbury were made by the family’s counsel team at the Inquest (and, if I may be permitted to observe, forcefully so) and that the issue of a lift was explored extensively in the evidence. It is apparent from that same review that a large number of points were made by counsel for the Police and the two officers in support of their position (Mr Gibbs KC’s submissions attempting a similar “highlights” package from their perspective, until discouraged by the court). It is also clear that the Coroner’s assessment of the state of evidence on the issue of the lift (including on the fact of its non-acceptance) was one chain in a lengthy list of reasons the Coroner gave for her evidential assessment.

89. 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. It is, with respect, simply not arguable that no reasonable tribunal, directing itself properly, could have reached the conclusions to which the Coroner came. Nor am I persuaded that it is arguable that the Coroner was not at all times fully alive to the differing roles of coroner and jury, or that she trespassed into the Jury’s realm. Ground 2

90. Ground 2 is that: “The Coroner erred in law by eliding the question of whether there had been a breach of the substantive Article 2 duty with that of whether there was sufficient evidence that there were any acts or omissions by the police that were potentially causative of Sabina’s death and which could be safely left to the jury.” The authorities on the treatment of causation in coroner’s inquests

91. I was referred to a number of cases which had addressed decisions by coroners to leave (or not to leave) causation issues to the jury.

92. R (Tainton) v HM Senior Coroner for Preston and West Lancashire [2016] EWHC 1396 (Admin) was an Article 2 inquest arising from a death in medical care of a serving prisoner. The coroner decided not to leave to the jury the issue of whether “admitted failings” by the prison medical services had caused or contributed to the prisoner’s death: i) 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” (that formulation reflecting the metaphysical reality that one event or state of affairs will ordinarily have multiple causes, with different causal potency from a legal perspective). ii) 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”. iii) 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]). iv) However, the Divisional Court concluded that the coroner had erred in not recording those admitted failings in the inquest record ([80]).

93. That last topic was concerned with recording in the inquest record findings of culpable acts or omissions which been admitted, but had not met the evidential threshold for a finding of causation. I was also referred to two decisions addressing the position of coroners sitting without juries in relation to such matters, and again confirming the coroner’s entitlement to record the findings of culpable acts or omissions, even if they were not causative: i) 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.” ii) 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'.”

94. All of these are cases in which the act or omission in question was either admitted, or supported by evidence to the requisite standard. What acts or events were “in play” at the Inquest?

95. It is important when considering this ground to consider the issues which had crystallised by the end of the evidence and submissions at the Inquest: i) Submissions were made to the Coroner as to the issues to be left to the Jury. ii) CTI identified three key issues as having been explored during the course of the Inquest: a) Whether the Police deliberately notified Paul Asbury and/or others of the whereabouts of Mark Williams? b) Whether the Police inadvertently notified Paul Asbury and/or others of the whereabouts of Mark Williams? c) 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? iii) On the second of those issues, CTI explored the issue of whether Paul Asbury was independently aware of Mark Williams’ presence at the police station. Counsel referred to the third issue by the shorthand “the Article 2 breach”. iv) So far as the Rizvi family are concerned, they identified three factual matters which it is said should have been left to the Jury “as they arguably appear to have caused or contributed to Sabina’s death”, which I have set out at [38] above.

96. These were the only “acts or omissions” of the Police “in play” when the Coroner gave her Galbraith ruling and they were all addressed: i) The Coroner found (in a conclusion which has not been challenged) that there was no case sufficient to go to the Jury that Roberto Florio’s conversation with Paul Asbury was “causative in any way of the death of Ms Rizvi” ([16]-[17]). ii) The “entire plan to harm Williams represented a significant escalation in the criminality of Paul Asbury that the police could not have fathomed on the information available that night” ([42]). iii) The Coroner noted at [33] that Leading Counsel for the family “in oral submissions accepted that the decision to bail [Mark Williams] is not subject to challenge and the police had no power to detain either [Mark Williams] or Sabina for their own protection” ([33]). That account of the course of the Inquest is not challenged on this application for judicial review, and is confirmed by my review of the transcript. Ground 2: conclusion

97. It is against that background that it is necessary to consider Ground 2. The Coroner did not leave issues of causation to the Jury because she had addressed the alleged acts or omissions of the Police which it was said were open on the evidence, and concluded that none passed the Galbraith test. Having made those findings, she stated ([57]): “I do not in these circumstances consider it necessary or appropriate to make findings as to causation”.

98. That last sentence clearly meant a Galbraith determination in relation to issues of causation (as Mr Stanbury fairly accepted).

99. A causal issue for a coroner’s jury necessarily involves the identification of alleged acts or omissions which it has been suggested may be causative, and a finding as to whether they are by reference to the test in Tainton . Having concluded that there were no relevant acts or omissions, I am satisfied that the Coroner was right to conclude that there were no causation issues in respect of the actions of the Police which should be left to the jury. Causation is not an issue which, in this context, could fairly or sensibly be approached in the abstract, but only by reference to acts or omissions alleged to be causative. This point had been recognised by Mr Menon KC for the family at the Inquest, when noting 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”

100. While Ground 2 argues that the Coroner erred in law by not considering “that there were any acts or omissions by the police that were potentially causative of Sabina’s death and which could be safely left to the jury”, that is exactly the question the Coroner asked, finding that there were no such acts or omissions satisfying the Galbraith test. The submissions made on behalf of Mrs Rizvi do not identify what acts or omissions Ground 2 is referring to. If Ground 2 has in mind matters not identified as “acts or matters” by the family or CTI at the Inquest, there can be no criticism of the Coroner for addressing herself to the submissions she did receive from those who had participated in the Inquest and followed all of the evidence. Any suggestion that potential acts or omissions were raised but not considered by the Coroner would have offered an obvious means of public law challenge, but none has been brought, no doubt because there is no basis for such a challenge.

101. In these circumstances, I am satisfied that Ground 2 is not arguable. Conclusion

102. For these reasons, the application for permission to bring proceedings for judicial review is refused.