Understanding Coroner's Verdicts
Coroner Conclusions Explained
At the end of an inquest, the coroner (or jury) reaches a "conclusion" about how the deceased came by their death. Understanding what different conclusions mean, how they're reached, and their legal implications can help you interpret the outcome of an inquest.
October 2025 Update:
The term "verdict" has been replaced with "conclusion" in coroner proceedings, though many people still use both terms interchangeably. The legal framework remains the same.
Important: Coroner conclusions are about how someone died, not who was at fault. Inquests establish facts but don't determine civil or criminal liability.
Standard Short-Form Conclusions
The coroner can choose from several standard conclusions:
1. Natural Causes
What it means: Death resulted from disease or natural deterioration of bodily functions without external cause.
Common examples:
- Heart attack or stroke
- Cancer
- Pneumonia or other infections
- Organ failure from chronic disease
- Age-related decline
Note: Even when death occurred in hospital or during medical treatment, if it resulted from natural disease progression, the conclusion is natural causes.
2. Accident or Misadventure
What it means: Death resulted from an unintended event or consequence of a lawful act.
Common examples:
- Road traffic accidents
- Falls resulting in fatal injury
- Accidental drowning
- Industrial accidents
- Accidental poisoning or overdose
- Complications from medical procedures (when procedure was appropriate)
"Misadventure" is used when the deceased contributed to their own death through their actions, but without intent (e.g., taking medication that caused unexpected fatal reaction).
3. Suicide
What it means: The deceased intentionally took their own life.
Standard of proof: Criminal standard (beyond reasonable doubt) that the person intended to take their own life.
Evidence required:
- Clear evidence of suicidal intent
- Act was deliberate and voluntary
- May include suicide notes, previous attempts, or clear method
If intent cannot be proven to this high standard, the coroner may conclude accident or open verdict instead.
4. Unlawful Killing
What it means: Death resulted from murder, manslaughter, or infanticide.
Standard of proof: Criminal standard (beyond reasonable doubt).
When it's used:
- Clear evidence someone unlawfully caused the death
- Usually follows or runs parallel to criminal proceedings
- Doesn't name individuals (that's for criminal courts)
Rare in practice. Often inquests are suspended if criminal proceedings are ongoing.
5. Lawful Killing
What it means: Killing was justified and lawful (e.g., in self-defense or military action).
Extremely rare. Used in specific circumstances like:
- Deaths in military action
- Police shootings deemed justified
- Lawful self-defense by third parties
6. Open Verdict (Open Conclusion)
What it means: Insufficient evidence to determine how death occurred with certainty.
When it's used:
- Cannot rule between accident and suicide
- Unclear circumstances with multiple possibilities
- Insufficient evidence for definitive conclusion
- Known cause of death but unknown how it came about
Example: Found drowned, but unknown whether accidental fall, suicide, or unlawful killing.
7. Industrial Disease
What it means: Death resulted from a disease contracted through employment.
Common examples:
- Asbestosis or mesothelioma
- Pneumoconiosis (coal workers' lung disease)
- Other occupational diseases
8. Drug/Alcohol Related
What it means: Death was directly caused by the effects of drugs or alcohol.
May be combined with:
- "Drug-related death" (overdose, whether intentional or accidental)
- "Alcohol-related death"
- Often accompanied by narrative to explain context
9. Stillbirth
What it means: Baby born dead after 24 weeks of pregnancy.
Stillbirths after 24 weeks are registered as stillbirths, not deaths. Inquests only occur if there are concerning circumstances.
10. Died from Want of Attention at Birth
What it means: Death of newborn due to lack of proper care during birth.
Very rare in modern practice due to improved maternity care.
Narrative Conclusions
Increasingly common, narrative conclusions provide a more detailed explanation:
What is a Narrative Conclusion?
A narrative conclusion is a brief statement describing the circumstances of death in more detail than a short-form conclusion allows. It can be used alone or with a short-form conclusion.
When Narrative Conclusions Are Used
- Complex deaths involving multiple factors
- When a short-form conclusion is too simplistic
- To highlight systemic issues or failures
- To provide more meaningful explanation to families
- In Article 2 (state duty) inquests
Example Narrative Conclusions
Example 1 (Medical setting):
"Mr. Smith died from complications of surgery to repair an abdominal aortic aneurysm. Contributing factors included delayed recognition of post-operative bleeding and insufficient critical care capacity at the hospital on that date."
Example 2 (Mental health):
"Ms. Jones died by hanging following discharge from psychiatric services. She had expressed suicidal ideation but risk assessment was inadequate and follow-up appointments were not provided."
Example 3 (Custody death):
"Mr. Brown died from acute drug toxicity while in prison. Prison staff failed to identify withdrawal symptoms and did not provide adequate medical monitoring despite known substance abuse history."
Why Families Often Prefer Narrative Conclusions
Narrative conclusions can capture nuance that short-form conclusions miss, acknowledge systemic failures, and provide a fuller understanding of what happened. They often feel more meaningful to bereaved families.
How Conclusions Are Reached
Standard of Proof
Different conclusions require different standards of proof:
- Civil standard (balance of probabilities): Natural causes, accident, drug-related, industrial disease
- Criminal standard (beyond reasonable doubt): Suicide, unlawful killing, lawful killing
Who Decides
The conclusion is determined by:
- The coroner: In most inquests
- The jury: In inquests that require a jury (deaths in custody, police contact, workplace deaths, etc.)
Coroner's Summing Up
At the end of evidence, the coroner summarizes the case and explains what conclusions are legally available. For jury inquests, the jury must choose from the options the coroner identifies as legally possible.
What Conclusions Don't Do
It's important to understand the limitations:
Don't Determine Guilt: Conclusions don't name individuals as criminally or civilly liable. That's for criminal or civil courts.
Don't Award Compensation: Inquests don't provide financial compensation. That requires separate civil litigation.
Don't Impose Penalties: Inquests don't punish individuals or organizations. Regulatory bodies or criminal courts handle that.
Don't Always Answer "Why": Inquests establish how someone died (the medical cause and circumstances) but can't always explain why in a deeper sense.
Prevention of Future Deaths Reports
Separately from the conclusion, the coroner may issue a Prevention of Future Deaths (PFD) report:
What is a PFD Report?
If the coroner believes there's a risk of future deaths occurring in similar circumstances, they must report this to the relevant organization(s) and recommend actions to prevent future deaths.
Who Receives PFD Reports?
- Hospitals or NHS trusts
- Government departments
- Local authorities
- Private companies
- Professional regulatory bodies
- Any organization with power to take preventative action
Responses Required
Organizations must respond within 56 days, explaining what action they'll take or why they won't act. Families receive copies of reports and responses.
Relationship to Conclusion
PFD reports are independent of the conclusion. A natural causes conclusion doesn't prevent a PFD report if systemic issues are identified.
Disputed or Unsatisfactory Conclusions
If you disagree with the conclusion:
Making Submissions
Before the coroner or jury reaches a conclusion, you (or your lawyer) can make submissions about what conclusion is appropriate and legally available. This is your opportunity to argue for a particular outcome.
Challenging After the Inquest
If you believe the conclusion was legally wrong:
- Apply to the Attorney General or Solicitor General
- They can apply to the High Court for a new inquest
- You need strong legal grounds (insufficient evidence, legal error, new evidence)
- Success rate is low – most applications are rejected
Judicial Review
In exceptional cases, you can seek judicial review of the inquest process itself (not the conclusion, but how the inquest was conducted). This requires legal representation and must be done promptly.
Understanding Medical Cause of Death
The conclusion is separate from the medical cause of death:
Medical Cause
This is the medical condition that directly caused death, recorded in standard format:
- 1a: Immediate cause (e.g., "cardiac arrest")
- 1b: Underlying cause (e.g., "myocardial infarction")
- 1c: Further underlying cause (e.g., "coronary artery disease")
- 2: Other significant conditions (e.g., "diabetes mellitus")
Conclusion
This describes how the person came to die in those circumstances (natural causes, accident, suicide, etc.). Same medical cause can have different conclusions depending on circumstances.
Record of Inquest Document
After the inquest, you'll receive a Record of Inquest:
What It Contains
- Who died, when and where
- The conclusion reached
- The medical cause of death
- Coroner's signature and date
What It's Used For
- Registering the death (if not already registered)
- Estate administration
- Insurance claims
- Civil litigation
- Regulatory proceedings
Getting Copies
You'll receive an initial copy free. Additional certified copies can be ordered from the coroner for a fee (usually £10-12 each).
How Conclusions Affect Other Proceedings
Criminal Proceedings
An unlawful killing conclusion may support criminal prosecution, but doesn't guarantee it. The Crown Prosecution Service makes independent charging decisions.
Civil Claims
Inquest findings can be used in civil litigation but aren't binding. You'll still need to prove your case to civil standard in a civil court.
Professional Regulation
Professional bodies (GMC, NMC, etc.) may investigate based on inquest findings, but make independent decisions about professional conduct.
Health and Safety Prosecution
The Health and Safety Executive may prosecute employers based on inquest findings, particularly if an accident conclusion reveals workplace safety failures.
Key Points About Conclusions
- • Conclusions describe how death occurred, not who was at fault
- • Different conclusions require different standards of proof
- • Narrative conclusions provide more detail and context
- • Open verdicts are used when circumstances remain unclear
- • PFD reports can be issued regardless of conclusion
- • Conclusions don't determine guilt, liability, or compensation
- • Challenging conclusions is difficult and rarely successful
- • The Record of Inquest is the official document you'll use going forward
Getting Support
- • INQUEST: 020 7553 0174 / inquest.org.uk – Advice on understanding and challenging conclusions
- • Coroner's Officer: Can explain the conclusion and its implications
- • Your Solicitor: If you had legal representation, discuss next steps
- • Bereavement Support: Cruse, Victim Support, and other organizations can help process difficult conclusions
Scotland and Northern Ireland
Scotland
Fatal Accident Inquiries in Scotland reach "determinations" rather than conclusions, with slightly different categories. The principles are similar but governed by different legislation.
Northern Ireland
Northern Ireland inquests use similar conclusions to England and Wales, with the same legal framework.
Related Guides
You might also find these guides helpful
When Deaths Go to the Coroner
Which deaths are referred to the coroner, what happens during an investigation, and how long the process takes.
Understanding Post-Mortem Examinations
Types of post-mortems, when they're required, what happens during the procedure, religious considerations, and timeline implications.
What Happens at an Inquest
Complete guide to coroner's inquests, who attends, the hearing process, giving evidence, and possible outcomes.