Introduction
At the conclusion of an inquest, the Coroner – or in some cases the jury – must reach a formal conclusion about the death.
For many families, conclusions are one of the most significant stages of the entire inquest process.
The conclusion records the Coroner’s (or jury’s) findings regarding how the deceased came by their death. In some cases, the conclusion is brief and straightforward. In others, detailed narrative findings may be required.
This article explains the different types of conclusions available at an inquest and how they are approached in practice.
What Is a Conclusion?
A conclusion is the formal outcome of the inquest.
Historically, conclusions were often referred to as verdicts, although the modern terminology used within the coronial system is generally “conclusion”. This distinguishes inquests from civil / criminal trials.
The conclusion must be based on the evidence heard during the investigation and hearing.
Importantly, a Coroner cannot determine either criminal liability on the part of a named person or civil liability.
The inquest process is investigative rather than accusatorial or adversarial.
Short-Form Conclusions
The most familiar conclusions are short-form conclusions.
Common examples include:
- Natural causes;
- Accident or misadventure;
- Suicide;
- Unlawful killing;
- Industrial disease;
- Drug or alcohol related death;
- Road traffic collision; and
- Open conclusion.
The appropriateness of any particular conclusion depends entirely on the evidence.
Natural Causes
A conclusion of natural causes is generally reached where the death resulted entirely from naturally occurring disease processes.
This conclusion may still arise even where medical treatment was involved, provided the treatment did not make a more than minimal or material contribution to the death or break the “chain of causation”.
Accident or Misadventure
Accident generally applies where death resulted from an unintended event following an unintended action.
Misadventure is more often used where the deceased intentionally undertook an act, but an unintended consequence resulted in death.
The distinction can sometimes become legally significant depending on the circumstances. This issue is looked into in greater depth in an article here
Suicide
A conclusion of suicide requires evidence that the deceased:
- Took a deliberate act; and
- Intended that act to result in death.
There are naturally some complications in this area, which you can read about here.
Coroners (or juries) can also make inferences from evidence that they have. This is considered in more depth here.
The standard of proof applicable to suicide conclusions is the civil standard – namely the balance of probabilities.
The leading authority is R (Maughan) v Her Majesty’s Senior Coroner for Oxfordshire [2020] UKSC 46.
Given the obvious sensitivity of such conclusions, Coroners generally approach these cases with considerable care.
Unlawful Killing
A conclusion of unlawful killing may arise where the evidence establishes conduct amounting to a criminal offence such as murder, manslaughter or gross negligence manslaughter.
These conclusions can involve particularly complex legal directions, especially where a jury is involved.
Although the Coroner cannot determine criminal guilt against a named individual, the conclusion itself can nevertheless carry very significant implications.
Open Conclusions
An open conclusion may be reached where the evidence does not sufficiently establish how the deceased came by their death.
This does not mean the investigation has failed. Rather, it reflects that the available evidence does not safely support a more definitive conclusion.
Open conclusions are sometimes seen where there are evidential uncertainties regarding intention, causation or surrounding circumstances.
Narrative Conclusions
In some cases, short-form conclusions are considered inadequate to explain the circumstances of the death.
The Coroner may instead, or additionally, provide a narrative conclusion.
A narrative conclusion sets out factual findings in greater detail.
For example, the conclusion may identify:
- Failures in communication;
- Delays in treatment;
- Systemic issues;
- Deficiencies in risk assessment; or
- Other factual matters relevant to the death.
Narrative conclusions are particularly common in Article 2 cases, healthcare deaths, custody deaths and other complex investigations.
Can Conclusions Criticise Individuals?
A Coroner must exercise care to avoid determining civil or criminal liability.
However, factual findings may still be critical of systems, procedures or organisational failings where supported by the evidence.
The distinction between permissible factual findings and impermissible findings of liability is often legally complex.
What Happens After the Conclusion?
The conclusion formally brings the inquest to an end. However, the findings may still have wider consequences.
Depending on the circumstances, the outcome may:
- Lead to a Prevention of Future Deaths Report;
- Influence disciplinary or regulatory proceedings;
- Affect related civil litigation; or
- Prompt wider organisational review.
Practical Takeaways
- The conclusion is the formal outcome of the inquest.
- Coroners or juries may reach short-form or narrative conclusions.
- Conclusions must not determine criminal or civil liability.
- Open conclusions are used where the evidence does not safely establish a more definitive outcome.
- Narrative conclusions are common in complex or Article 2 inquests.
Final Thoughts
The conclusion reached at an inquest is often of profound importance to families and Interested Persons alike.
While the process cannot determine liability in the way a civil or criminal court can, the factual findings made during an inquest may nevertheless have substantial practical and emotional significance.
Understanding the different forms of conclusion can help families engage more confidently with the process and better understand the legal framework within which Coroners operate.