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

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

The coroner erred by failing to direct the jury to consider whether the prison healthcare's admitted failure to arrange an ECG in May 2018 was a possible causative or contributory factor, and fettered her discretion by not calling a GP witness; however, these errors do not warrant quashing the Record of Inquest or ordering a fresh inquest due to evidential gaps and lack of material impact.

Parties
Claimant: Eileen Henshaw; Defendant: HM Assistant Coroner for Derby and Derbyshire; Interested Party: Ministry of Justice; Interested Party: Practice Plus Group
Jurisdiction
England and Wales
Judgment Date
20 February 2025
Procedural Posture
Judicial Review / Final Judgment
Outcome
Declaratory relief granted; application for quashing order refused; no fresh inquest ordered.
Legal Topics
Article 2 Inquest, Death in Custody, Medical Negligence, Coroner's Directions, Judicial Review, Procedural Fairness
Public Law Coroners Law Human Rights Article 2 Inquest Death in Custody Medical Negligence Coroner's Directions Judicial Review +1 more

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Parties

Eileen Henshaw

Claimant

HM Assistant Coroner for Derby and Derbyshire

Defendant

Ministry of Justice

Interested Party

Practice Plus Group

Interested Party

Procedural Posture

Judicial Review / Final Judgment

Legal Issues

  1. 1 Whether the coroner erred in directing the jury on natural causes and excluding accidental death as a possible verdict
  2. 2 Whether the coroner unlawfully withdrew potentially causative issues (ECG failings, GP summary omissions, prison officer checks) from the jury's consideration
  3. 3 Whether the coroner fettered her discretion by not calling a GP witness

Ratio Decidendi

The coroner erred by failing to direct the jury to consider whether the prison healthcare's admitted failure to arrange an ECG in May 2018 was a possible causative or contributory factor, and fettered her discretion by not calling a GP witness; however, these errors do not warrant quashing the Record of Inquest or ordering a fresh inquest due to evidential gaps and lack of material impact.

Court Disposition

Declaratory relief granted; application for quashing order refused; no fresh inquest ordered.

Orders

  • Declaration that the coroner erred in failing to direct the jury to consider whether the prison healthcare's admitted failure to arrange an ECG in May 2018 was a possible causative or contributory factor in the onset of sudden cardiac arrythmia leading to death.
  • Declaration that the coroner fettered her discretion and acted unlawfully in deciding not to call a GP witness to explain the omission in the GP summary sent to the prison on 10 July 2017.