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Inquest Conclusions, Verdicts and Evidence

Inquest Representation

During an inquest the coroner has to gather the information to complete the Record of Inquest Form that gets sent to the Registrar of Deaths. For most interested persons the key parts of the form are Box 3 and Box 4.  At the end of an inquest the coroner sums up the evidence he has heard (or that has been read into the record) and goes on to state the specific findings of fact he has made.  These findings go into Box 3.  The conclusion is written into Box 4.  When the Coroner’s and Justice Act 2009 came into force the term “conclusion” replaced “verdict”. It is still not unusual for press and media reports to use the term” verdict”. If the case has been straightforward and does not need any additional explanation most coroners will put a short form conclusion in Box 4 such as natural causes, accident, road traffic collision, suicide. To be able to put a short form conclusion the coroner must have made findings of fact that allow that conclusion. If not, the default is an open conclusion. Until very recently the coroner had to be satisfied beyond reasonable doubt before he could enter a conclusion of suicide. In  July 2018 the High Court in Maughan, R v Senior Coroner for Oxfordshire [2018] EWHC 1955 (Admin). the court ruled that the balance of probabilities was the correct standard of proof for a conclusion of suicide.

For an enhanced Article 2 inquest or more complex non-Article 2 inquests a narrative conclusion is more usual. Even so these are supposed to be short and restricted to the facts that contributed to the death. On occasion, the coroner can add a neglect rider to a short-form or narrative conclusion. This is different from a finding of negligence in civil proceedings. In order to add a neglect rider the coroner must be satisfied on the balance of probabilities that certain criteria have been met by the evidence and findings of fact he has made. Case law has determined what these criteria are. Chief Coroner’s Guidance No.17 Conclusions: Short-Form and Narrative Read guidance

 At the end of all the evidence presented at the inquest hearing legal representatives for interested persons and non-represented interested persons can address the coroner on the law and what conclusions he could properly consider. Before the inquest hearing the coroner will release to the interested persons the witness statements and other evidence that will be considered at the inquest. If there are any issues that might lead to a neglect rider it can be very helpful to the bereaved family  or interested persons who might be implicated, to take legal advice on the most likely conclusion  and  the possibility of a neglect rider.  This can only be based on the written evidence.  If there is no prospect of meeting the legal criteria for certain conclusions or a neglect rider, early identification of this can help to manage expectations of what can be achieved at the inquest. Equally a timely legal review of the evidence can identify issues that the coroner has not considered that might be relevant to his determination or the scope of the inquest. This can be brought to the coroner’s attention in advance of the inquest hearing so that it can be considered, perhaps by calling a pre-inquest review hearing. Consideration can be given whether an independent expert should be instructed. The inquest lawyers at Alexander Chambers are very experienced in providing a review and advisory service. 

As part of the investigation process before an inquest hearing the coroner may request witness statements or reports from various individuals or corporate bodies.  The coroner is undertaking a fact-finding process. He is not judging an adversarial case with opposing parties, so the style and content of an inquest statement is different from other types of cases. The statement from a member of the deceased’s family may need to combine a pen portrait of the deceased’s life as well as a factual statement setting out the sequence of events leading to the death from the family’s personal experience.  Some health professionals such as agency nurses may not get support to prepare their witness statement from a care home or hospital trust.  Alexander Chambers provide s a service to advise and assist with witness statements.  Apart from families we have helped health care support workers, nurses, care home staff, psychiatrists, doctors, civilian police staff, paramedics and friends of the deceased.

If you would like to discuss any aspect of an inquest case in confidence and without obligation please call Alexander Chambers on 0845  652 0451 and ask to speak to one of our inquest lawyers.


Other Articles on Inquests:

Representation at inquests
Coroner Investigations and Conclusions
Challenging the coroner's decision
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