What Does a Suicide Conclusion Mean?
A conclusion of suicide means that the Coroner or Jury is satisfied that:
- The deceased took their own life, and
- They intended to do so.
It is a serious and carefully scrutinised conclusion. Coroners are required to direct themselves or the Jury with particular care before it can be returned.
Chapter 15 of the Chief Coroner’s Bench Book provides guidance to Coroners on directing Juries in suicide cases, emphasising the need to consider both the act and the intention. So suicide is not established merely because a death was self-inflicted. Intention is central.
For a general overview of the inquest process, see About Inquests.
The Standard of Proof: Balance of Probabilities
For many years, suicide had to be proved to the criminal standard – which we used to describe as beyond reasonable doubt.
(Whilst this phrase persists, the formulation “so as to be sure” is increasingly used.)
That criminal standard for suicides changed in R (Maughan) v HM Senior Coroner for Oxfordshire [2020] UKSC 46.
The Supreme Court held that the civil standard of proof applies to all inquest conclusions, including suicide and unlawful killing. At §97, Lady Arden stated:
The standard of proof for all short form conclusions at an inquest is the balance of probabilities.
This means that a Coroner or Jury must now be satisfied on the balance of probabilities – in other words, that it is more likely than not – that the deceased intended to take their own life.
This was a significant development in coronial law.
How Juries Are Directed
The Chief Coroner’s Bench Book provides practical guidance to Coroners when directing a Jury on suicide.
It emphasises that:
- The Jury must be satisfied that there was an intentional act for the deceased to take their own life (now assessed on the civil standard – the Jury do not have to be “sure”).
- Evidence of intention can be direct or inferred.
- Care must be taken not to speculate.
The Coroner will normally summarise the evidence relevant to intention, including, for example:
- Mental health history
- Statements or communications
- Behaviour shortly before death
- Toxicology evidence
Common Issues That Arise
Families often face difficult evidential questions such as:
- Was this a deliberate act or an impulsive one?
- Was the deceased capable of forming intent? (They may not have been if under the influence of drugs)
- Could this have been an accident?
- Might the deceased have intended to take a harmful, but non-fatal act?
- Was medication, alcohol or drug use a factor?
In some cases, where intention cannot be established on the balance of probabilities, the Coroner or Jury may return a conclusion of misadventure, or accident. Less frequently, an Open Conclusion may be returned instead.
When Suicide Is Disputed
A suicide conclusion may be challenged where:
- There is insufficient evidence of intent
- The Coroner misdirects the Jury
- Relevant evidence of the act or intention was excluded
- The balance of probabilities test was wrongly applied
Such challenges are rare but may be brought by way of Judicial Review.
Early advice from a Barrister experienced in inquests can be critical in ensuring the correct legal approach is taken at the hearing itself.
A Final Word for Families
A suicide conclusion is never reached lightly. It requires careful legal analysis and structured direction.
If you are concerned about the possibility of such a conclusion, or if you believe the evidence does not justify it, I can advise on:
- The legal test
- The standard of proof
- Submissions to the Coroner
- Representation at the inquest
You can find further practical guidance in Resources & News, or contact me here to discuss your situation in confidence.