Conclusions that can be reached at the end of an inquest.

Inquest basics: Conclusions

In the fifth of a series of articles delving into the world of inquests, Charlotte Davies (2007) examines the conclusions that can be reached at the end of an inquest.

The Coroner’s Court is a fact-finding inquiry rather than an adversarial trial, and so it reaches a “conclusion”, as opposed to a “verdict”.?The use of the term “verdict” was removed from the inquest process in July 2013 when various parts of the Coroners & Justice Act 2009 came into force, albeit you may still see the phrase used (wrongly) in press reports.

The purpose of this final stage of the process is to answer the “how” of the “who, where, when and how” questions the coroner must answer.

Legal representatives acting for the Interested Parties can make submissions about which conclusion(s) the coroner should consider, with representatives only being allowed to make submissions on the law, and not on the facts. Coroners are reminded by the Chief Coroner’s Guidance that they should at all times use moderate, neutral and well-tempered language, befitting the holder of a judicial office.?

The coroner is required to arrive at a conclusion by way of a three-stage process.

1.?To make findings of fact based upon the evidence.

The coroner will make key findings of the evidence that they have heard. The standard of proof on which they will do this is the civil standard.

2.?To record by what means the deceased came by their death.

This will usually be a description of the mechanism of death such as ‘by drowning while swimming in the open sea’ or ‘hanging from a beam using a rope as a ligature’. Coroners, in their judicial discretion, will use their own form of words which should be brief, neutral and clear. They must not include opinion other than on matters which are the subject of statutory determination (s.5(3), 2009 Act) and they must not appear to determine any question of criminal or civil liability on the part of a named person (s.10(2)).

3. The conclusion will either be what is known as a ‘short-form’ conclusion or a narrative conclusion.

Short Form?

Some examples of short form conclusions are:

Natural causes?– This is considered be the normal progression of a natural disease or illness, where a naturally recurring disease runs its full course without any significant amount of medical care or human intervention;

Suicide?– This is defined as a deliberate act by the deceased and that the intended consequence of this act was, at all times, to be death. The requirement that a conclusion of suicide had to be made on the criminal standard of proof was removed by the Supreme Court in the case of R (Maughan) v HM Senior Coroner for Oxfordshire [2020] UKSC 46;

Accident/misadventure?– an unnatural event which was neither unlawful nor intended by the deceased to result in death.?

Industrial disease?– when the death resulted from a disease caused by work;

Alcohol/drug-related?– this can cover an accidental death resulting from abuse of alcohol or drugs, or from death being the result of being addicted to alcohol/drugs;

Open - this is used when none of the other conclusions are appropriate and/or the evidence does not fully explain the circumstances of the death. For example, where there is insufficient evidence as to intent to record a conclusion of suicide.

?

A Narrative?Conclusion

This is an ‘alternative’ to a short-form conclusion whereby the coroner may record a ‘brief narrative conclusion’ which goes into more detail regarding the factual findings.

Narrative conclusions may be used in both Article 2 and non-Article 2 cases. In a non-Article 2 case, a narrative conclusion should be a brief, neutral, factual statement; it should not express any judgment or opinion. For example, in a clinical death, a narrative conclusion might state that the deceased died from recognised complications of a surgical procedure.

If the inquest is an Article 2 inquest, the wording used in a narrative conclusion can be judgmental. For example, in a non-Article 2 case judgmental words such as ‘missed opportunities’ or ‘inadequate failures’ should be avoided. This is why there is often significant argument over whether an inquest should be Article 2 or not. Interested Parties may be seeking to avoid the prospect of there being a narrative conclusion which includes judgment or critical wording.

The higher courts have repeatedly emphasised the need for brevity in a narrative conclusion. A sentence or two, or a single short paragraph, will be sufficient.

Charlotte has appeared in numerous multi-day inquests representing all types of interested parties, including Article 2 and jury inquests. She has appeared in a number of inquests reported in the national press, including those involving Leading Counsel. She has particular experience at inquests involving young people taking their own lives.

If you wish to discuss anything in this article or you want to instruct Charlotte you can contact her clerk on [email protected].