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Inquests: Conclusions


    Inquest specialist, Ali Cloak, considers the different conclusions which can be reached in an inquest and their implications.

    By Ali Cloak


The purpose of an inquest is to identify the deceased and the time, place and circumstances of their death. The conclusion, previously known as the verdict, is the formal summary of how the death occurred.

There are a number of potential conclusions which can be reached in an inquest in England & Wales:

  • natural causes;
  • industrial disease;
  • dependence on drugs/non-dependent abuse of drugs;
  • want of attention at birth;
  • suicide/killed him or herself whilst the balance of his or her mind was disturbed;
  • accident or misadventure;
  • disaster which is the subject of a public inquiry;
  • attempted or self-induced abortion;
  • lawful killing;
  • unlawful killing;
  • open verdict
  • stillbirth;
  • narrative verdict

All of these conclusions have to be established to the test of the ‘balance of probabilities’, i.e. more likely than not, except for suicide and unlawful killing, which have to be proved ‘beyond reasonable doubt’, which is a higher standard.


I will explain the most common of the conclusions in more detail below:

Natural Causes

This would apply where the death was caused by the normal development of a natural illness which was not significantly contributed to by human intervention.

Accidental Death

This would apply where the person died as a result of actions by themselves or others that had unintended consequences; where the cause of death was unnatural but not unlawful.


This is similar to ‘accidental death’ but generally is used where it is found that the deceased had taken a deliberate action that has then resulted in the death.


For a conclusion of suicide to be determined, there has to be clear evidence which shows that the deceased intended to take their own life. A suicide note may be evidence of such intent, but is not in itself determinative. If there is insufficient evidence of the deceased’s intent to take their own life, then an alternative conclusion of misadventure, accidental death or an open conclusion may apply instead.

Open Conclusion

This is the conclusion reached where there is simply not enough evidence to return one of the other conclusions, This is generally quite a rare verdict and really only used as a ‘last resort’.


In some cases the words “contributed to by neglect” can be added to one of the short-form conclusions above. However, the law is very limiting as to when this can be applied and neglect does not mean the same in law as it does in everyday language. For a finding of neglect to be established, the coroner or jury have to be satisfied 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.

Narrative conclusion

In addition to the ‘short form’ conclusions set out above, it is also open to the Coroner or Jury to record a narrative conclusion, which is paragraph or several paragraphs which seek to explain the circumstances in a descriptive way.

This can often be a more helpful conclusion, and is often preferred by family members of the deceased as it can refer to a wider range of circumstances than a simple short form conclusion. A narrative conclusion could also include reference to neglect if that was felt appropriate.

Reports to Prevent Future Deaths

The coroner is under a duty to make a recommendation for change if he or she feels that the death could have been prevented. The coroner will send the report to whoever they have identified as being the appropriate authority for reviewing the issue. They then have 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.

Regulation 28 Reports, as they also known, are now published on the Government website www.judiciary.gov.uk and are accessible to the public, so that those involved are held to account.

These can be incredibly important for family members of the deceased, who are grateful to know that their loved one has not died in vain, and that further deaths will be prevented as a result of the inquest process.

If you would like to discuss any aspect of an inquest please do not hesitate to get in touch.


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