The Health and Care Brief – High Court Rules on Inquest Failings in R (Henshaw) v HM Assistant Coroner for Derby and Derbyshire [2025]

The Claimant, Ms Henshaw’s mother, challenged the findings of the Article 2 inquest, alleging that procedural errors and evidential omissions had compromised the jury’s ability to reach an appropriate conclusion. The judgment, delivered by Mr Justice Jay, highlights the court’s careful approach to balancing procedural fairness with the principles of finality and proportionality in coronial proceedings.

Background

Georgina Henshaw, aged 37, died in her prison cell while serving a life sentence for murder. She had a known psychiatric history and had been prescribed anti-psychotic medication associated with long QT syndrome – a rare cardiac condition that can cause fatal arrhythmias.

Her GP records from June 2017, which were not shared with prison authorities, included a clear warning not to prescribe further anti-psychotic medication pending psychiatric review, due to a prolonged QTc interval and a history of recurrent overdoses. Despite this, no follow-up ECGs were performed after her incarceration, and the warning was not reflected in the GP summary sent to the prison in July 2017.

On the morning of 31 August 2018, Ms Henshaw was found unresponsive in her cell. Although CPR was attempted, including the use of an I-gel airway device (which was later found to have been incorrectly inserted), she was pronounced dead. Expert evidence concluded that she likely suffered a sudden cardiac arrhythmia between 8:10am and 8:40am.

The jury recorded a verdict of natural causes, guided by the Assistant Coroner’s direction that accidental death was not an available conclusion. The Claimant challenged the outcome on three grounds.

Grounds of challenge

Failure to leave accidental death to the jury

The Claimant argued that the jury should have been directed to consider a verdict of accidental death, on the basis that the incorrect insertion of the I-gel may have hastened the deceased’s death.

Mr Justice Jay agreed that the direction was lacking but concluded that the procedural error was not material. He found that the I-gel’s incorrect insertion likely hastened death by only a few minutes and had a de minimis impact. He relied on the authority of R v Birmingham & Solihull Coroner ex p. Benton [1997] 162 J.P. 807, confirming that where a patient dies from an underlying natural condition despite flawed medical care, the proper conclusion may still be one of natural causes.

Exclusion of Medical and Custodial Evidence

The Claimant also argued that the Assistant Coroner erred by withdrawing critical factual issues from the jury, including:

• The adequacy of the 8:25am welfare check by prison staff;
• the failure to perform ECGs in July 2017 and May 2018; and
• the failure to transmit the GP’s warning of June 2017.

While Mr Justice Jay accepted that these matters may have been relevant, he found no sufficient evidential basis to suggest they caused or contributed to death. Nonetheless, he acknowledged that the admitted failure to perform the May 2018 ECG and the omission of the June 2017 warning could fall within the scope of Tainton – that is, admitted failings that, while not proven causative, form part of the relevant circumstances of death.

Failure to Call a GP Witness

Finally, it was argued that the Coroner acted unlawfully by failing to call a witness from the GP practice, or by refusing to designate the GP an interested person under the Coroners and Justice Act 2009.

Mr Justice Jay agreed that this fettered discretion and was therefore unlawful, but held that the error did not justify a fresh inquest. He noted that, due to the passage of time, further useful evidence from the GP was unlikely.

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Take Me There

Outcome

The High Court refused to quash the Record of Inquest or order a fresh hearing. However, in line with the approach taken in R (Tainton) v HM Senior Coroner for Preston and West Lancashire [2016] EWHC 1396 (Admin), Mr Justice Jay granted declaratory relief to formally record the Coroner’s procedural errors.

The judgment included the following key declarations:

1. The Assistant Coroner erred in failing to direct the jury to consider whether the prison healthcare service’s admitted failure to arrange an ECG in May 2018 may have contributed to Ms Henshaw’s death.
2. The Assistant Coroner acted unlawfully by fettering discretion in deciding not to call a witness from the GP practice, whose evidence could have addressed why the June 2017 warning was omitted from the summary sent to the prison.

Conclusion

This decision reflects the judicial reluctance to disturb inquest findings in the absence of clear, causative errors. Importantly, it affirms the principle that declaratory relief may be appropriate to acknowledge procedural defects without reopening proceedings unnecessarily.

The case also reinforces the broader significance of R (Tainton)—requiring coroners to include admitted but non-causative failings within the record of inquest, where such failings form part of the circumstances of death under section 5 of the Coroners and Justice Act 2009.

From a practical perspective, this case is a reminder to practitioners representing interested persons at inquests to be alert to:

• The evidential threshold required to justify a change to the Record of Inquest;
• the necessity of making clear, well-supported submissions for jury directions and witness evidence; and
• the growing use of declaratory relief as a proportionate remedy in complex inquest challenges.

If you would like further advice on inquest representation or judicial review proceedings in the coronial context, please contact our specialist inquest team.