Burnetts logo

Inquest verdicts explained

Inquest verdicts explained

Medical negligence solicitor Lynne Hall provides a detailed explanation of inquest verdicts.

Inquest Verdicts explained

Attending an Inquest can be a daunting experience, especially if the Inquest is touching upon the death of a close relative or friend. It is easy to understand the process of calling and questioning  witnesses, but understanding the final outcome of the Inquest requires a more detailed knowledge of the law concerning Inquest Verdicts.

Inquest Verdicts or Findings of Fact?

Technically, the Coroner makes a ‘finding of fact’ at the end of an Inquest. The Coroner cannot attribute blame to any individual and cannot imply a criminal or civil liability. The Coroner must use the evidence heard to decide who the deceased person was, where they died, when they died, and what the cause of their death was.  Commonly, the ‘finding of fact’ is referred to as a verdict.

‘Short form’ Inquest Verdicts

The following are the most common ‘short form’ inquest verdicts arising along with their explanations:

  • Natural Causes- the death was caused by the normal development of a natural illness which was not significantly contributed to by human intervention.
  • Accidental Death- the cause of death was unnatural but not unlawful.
  • Misadventure- this is nearly the same verdict as ‘accidental death’ but would imply that the Deceased has taken a deliberate action that has then resulted in his or her death.
  • Suicide- it is decided that the person has voluntarily acted to destroy his or her life in a conscious way.
  • Neglect- there has been a gross failure to provide the Deceased with his or her basic needs i.e. the provision of nourishment, liquid, warmth or medicine. There must be a clear causal link between this gross failure and the death of the dependent person. This is a rare verdict and commonly associated with the failure to provide even basic medical attention. More commonly the Coroner would consider neglect as a contributing factor rather then the sole cause of death.
  • Unlawful Killing- the death was caused by murder, manslaughter, infanticide or through a serious driving offence.
  • Open verdict- there is simply not enough evidence to return a verdict. This is a rare verdict and really only used as a ‘last resort’.

Narrative verdict

The above list is not exhaustive and the Coroner has no obligation to use a short form verdict at all. The Coroner can use a ‘narrative verdict’, which will set out the circumstances of the death in a detailed way based on the evidence that the Coroner has heard. For those attending an Inquest of a beloved one, it can sometimes be more satisfying to hear the Coroner’s verdict in this form,  as more of a detailed conclusion of events leading to the death is provided by way of the Inquest verdict.

The Jury

In rare circumstances, a Jury will be used at an Inquest, for example if the death occurred whilst the person was in police custody or if the Coroner believes it would be in the public interest for there to be a jury. If a Jury is being used at the Inquest, the Coroner will decide which conclusions would be reasonable for the Jury to make before the Jury deliberate as to the final Inquest verdict.

The standard of proof

Most of the Inquest verdicts must be decided ‘on a balance of probabilities’. In other words, by saying ‘it is more likely than not’ that the death of this person happened in this way. However, Inquest verdicts of Suicide or Unlawful Killing must be decided ‘beyond reasonable doubt’. 

Rule 43

Rule 43 of the Coroners Rules 1984 states that if the Coroner is of the opinion that a death could have been prevented if different action had been taken by a particular person or organisation, the Coroner can make a recommendation for change. The organisation in receipt of the Coroner’s recommendation (typically in the form of a report) has 56 days by law to respond in writing.

The response commonly includes confirmation that a certain practice or protocol has changed following the Coroner’s recommendation.  For example, a particular hospital Trust may be asked to review one of their policies as a protective measure for other patients. Rule 43 reports and responses are now published on http://www.judiciary.gov.uk and are accessible to the public.

 If you would like further information regarding  Inquest verdicts, please contact Lynne Hall of our Medical Law Team at ljh@burnetts.co.uk 

About the Author

Lynne Hall profile photo

Lynne Hall

Associate Solicitor Lynne is a specialist in Medical Negligence.

Published: Friday 26th June 2015
Categorised: Medical Negligence

Add your comments on this post

New comments on this post are no longer being accepted.

Comments on this post

Mark Taylor said 4 years ago

Very helpful article.

Thank you.