R (Robinson) v HM Assistant Coroner for Blackpool & Fylde and Chief Constable of Lancashire Police [2025]
Trainee Solicitor, Eve Burns, outlines the recent Judicial Review decision in R (Robinson) v HM Assistant Coroner for Blackpool & Fylde and Chief Constable of Lancashire Police [2025], and asks Weightmans’ specialist Inquest advocates about the implications for each of our police force, FRS, ambulance service and NHS Trust clients.
Weightmans were instructed by North West Ambulance Service at the original inquest and has a wide breadth of specialist experience in this area. This judicial review (JR) raises important points on Article 2 ECHR and Prevention of Future Death Reports (“PFDRs”), the latter being something we know is important to our clients but is rarely mentioned in the higher courts.
The inquest
Mr Robinson drove a registered stolen vehicle through Blackpool in 2021, triggering the Lancashire police vehicle ANPR camera. There was a short police chase before Mr Robinson stopped. Officers attempted to restrain him during which Mr Robinson placed a package into his mouth and became unresponsive. The police officers requested an ambulance and started CPR.
The package contained drugs and had caused a blockage in Mr Robinson’s airway. Paramedics required forceps to remove the package, and Mr Robinson was taken to hospital and died from fatal acute upper airway obstruction. The incident was recorded on the police’s dash cam and body worn footage, which was played to the jury during the inquest.
At the 2022 inquest, the family argued that Article 2 had been engaged as the police had failed to protect Mr Robinson’s life, and that excessive force was used. They argued the coroner should leave the conclusion of unlawful killing and neglect to the jury.
The coroner declined to engage Article 2, leaving the conclusion of misadventure and a narrative to the jury. The jury returned a conclusion of misadventure.
The coroner also wrote a Letter of Concern to the National College of Policing as opposed to issuing a PFD report. The Letter requested there be further training in respect of removing drugs packages from detainees and the handling of this.
Judicial review
At a hearing in January 2025 the family applied for judicial review of the coroner’s decision not to engage Article 2; the decision to write a Letter of Concern instead of a PFDR and as to the inadequacy of the coroner’s summing up to the jury.
The High Court dismissed the family’s application, upholding the coroner’s decision.
Article 2
Article 2 imposes a procedural obligation on the state to conduct an investigation in listed circumstances, including where the state owed a duty to take reasonable steps to protect the person’s life because the person was under the state’s control or care and the state knew (or ought to have known) there was a real and immediate risk to the person’s life.
In this case, the court was not willing to extend the categories where the state’s positive operational Article 2 obligations automatically arises.
The family argued that the circumstances of the death of Mr Robinson were grounds for the responsibility of the state to have a positive obligation to protect the life of Mr Robinson, and so therefore Article 2 should have been engaged and an investigation carried out. They argued that the court should extend the categories of cases where the state’s Article 2 obligations automatically arise so as to cover circumstances such as this.
The family also argued that the police officers knew or should have known that there was a real and immediate risk to Mr Robinson’s life and so there was a breach by the state of the positive operational duty to protect life under Article 2.
The court did not agree and did not find reason to extend the categories of cases whereby Article 2 is automatically applied. It concluded that: “Misadventure cases are not apt to attract the automatic application of article 2 because the misadventure may be unpredictable; the state agents may bear no blame for it; and it may require urgent medical attention beyond their expertise, where the state’s obligation would be, at most, to call for it and do their best with first aid meanwhile.”
The court held that the circumstances of the death must be such that “they fall into a category which necessarily gives rise, in every case falling within the category, to a legitimate ground to suspect state responsibility by way of breach of a substantive article 2 obligation” (Popplewell LJ in Morahan at [122(7)]).
The court also reinforced the high threshold for the test for imposing an Article 2 operational duty.
Failure to issue a PFDR
The coroner’s Letter of Concern to the College of Policing included the recommendations of Dr Forrest, the medical director of the Anaesthesia, Trauma and Critical Care (ATACC) Group, that removal of the drugs packages and subsequent management should be highlighted nationally to senior officers in each force.
The family alleged that the coroner evaded his statutory duty to issue a PFDR and “that to write a “letter of concern” instead was contrary to that duty and to the chief coroner’s guidance document called “Revised Guidance No. 5” dated 4 November 2020” (para 96).
The court disagreed, finding that the coroner was correct to sound out those with the power to take such action on what their view was on whether action should be taken. The court concluded that this was a properly considered and rational view to take and in line with Revised Guidance No. 5. It was not in every case where the coroner has concerns that future deaths will occur, that they will conclude that “action should be taken”, and therefore the duty to issue a PFDR will arise.
Furthermore, the court concluded that even if JR of the failure to issue a PFDR had been successful, this would not lead to the direction of a fresh inquest. (para 104).
Conclusions and commentary
The court concluded that there has to be a balance between the growth of narrative verdicts and discouragement of lengthy narrative accounts of the circumstances of a death.
The court stated that a fresh inquest would not elicit any new facts.
It outlines the possibility for coroners to raise some issues outside of the PFDR structure.
What this means for your organisation
Our specialist inquest advocates consider the implications of the decisions for different public sector organisations:
Ambulance services
Martin English:
“This is a helpful judgment that can be added to the bank of other judgments arising out of recent judicial review proceedings that assist state agencies when arguing against the engagement of Article 2. This judgment will be particularly important for Ambulance Trusts who very often find themselves called to assist patients in life-threatening situations and are therefore often required to make submissions with respect to the operational engagement of Article 2 on that basis.
The judgment also gives Ambulance Trusts support for arguing that a ‘Letter of Concern’ as opposed the issuing of a Regulation 28 Report, would be a more appropriate action to take where specific circumstances apply, namely in those cases where it would be sensible to first determine whether action should be taken with respect to a specific issue. This may be particularly relevant to Ambulance Trusts where issues arise at inquest that pertain to complex operational or medical matters”.
Weightmans represented NWAS at the original inquest in this matter. Martin English and Jess Swift regularly represent ambulance services at inquests and acted for NWAS at the Manchester Arena Bombing inquiry.
Read MorePolice forces
James Muller:
“Both Police Forces and Officers will be encouraged by the recognition from the High Court that Officers are often faced with unpredictable behaviour from the public, and that they will often bear no blame even where death occurs from such behaviour. The Court was critical of attempts to judge the actions of officers with hindsight, and recognised the competing priorities and concerns of officers (in this case, concerns that the suspect might produce a weapon), and that they cannot always carry out a full risk assessment before restraining an individual.
The Court specifically rejected attempts to by the family to argue that, effectively, any unnatural death during an arrest or in custody should automatically result in an Article 2 inquest. This is the sort of argument often run by those representing families at inquests involving the Police.
This case will likely be one often quoted by those representing Police Forces when resisting arguments from the family that Article 2 is engaged, and should mean that such arguments from the family are less likely to succeed.”
James Muller regularly represents police forces during inquests, and also provides police forces with advice policy and operational areas such Right Care Right Person.
Read MoreFire and rescue services
Natalie Puce:
“FRSs often face situations in which the public act unpredictably, and so the recognition that the threshold for the engagement of Article 2 in such cases is a very high one, is positive for FRSs.
It will also be reassuring for FRSs and Firefighters that the Court specifically recognised that not all emergency services have the medical expertise of the ambulance service / paramedics, and cannot be judged as if they did.
With many competing training priorities for Firefighters, it was also important that the Court and Coroner recognised that it was not always for them “to dictate priorities in the training agenda”, and that it would not always warrant a formal PFD where it was noted that certain training “may be beneficial”.
Natalie Puce has over 15 years’ experience representing fire and rescue services at inquests and public inquiries (including at the inquiry into the Manchester Arena Bombings).
Read MoreNHS trusts
Nichola Halpin:
"The decision will be of interest to those involved in NHS inquests in so far as how Article 2 may or may not be brought into play in cases involving misadventure.
This case also reaffirmed the principle that challenges or issues relating to PFD reports, as matters ancillary to the main inquest, would not lead to a fresh inquest being ordered even if the coroner’s approach was found to be flawed. This reinforces the line of authorities in Ayesha Siddique v Assistant Coroner for the Eastern Area of Greater London [2017] and R (On the application of Diarra Dillon) v HM Assistant Coroner for Rutland and North Leicestershire & Others [2022] EWHC 3186 (KB) (Admin).
It is also interesting to note that the High Court preferred the word ‘verdict’ to ‘conclusion’ in the judgment, notwithstanding the fact that changes to coronial law in 2013 introduced the term ‘conclusions’ to replace ‘verdict’ in order to reflect the non-adversarial nature of proceedings."
Nichola Halpin has over 10 years’ experience working for the NHS, representing NHS trusts at inquests, before joining Weightmans last year,
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