Inquest Conclusions and Reports to Prevent Future Deaths

Inquest Representation Service

At the end of an inquest the Record of an Inquest form has to be completed with certain pieces of information that are required by law to answer the 4 questions, who, how, when and where the deceased came by his death. Technically the whole of the Record of an inquest form is the conclusion ( this used to be called the verdict) but the general perception is that the answer to the “how” question is called the conclusion.

For most of the people who are involved in an inquest the conclusion is seen as the most important part of the process, although the limitations on the ambit of an inquest can mean wider issues of concern are not scrutinised by the coroner. Sometimes in relation to a hospital death the family of the deceased are hoping for a conclusion that might possibly lay the foundation stone to consider bringing a civil claim against the hospital trust and individual clinicians who dealt with the care of their loved one. (It should be noted the legal principles to be applied will be very different). Or, the family may not want a conclusion of suicide to be returned. A doctor or other health care professional whose care of the deceased has been called into question will want to avoid a conclusion with a neglect rider (see below) or, a finding that he contributed in some way to the death because of the potential ramifications for his professional standing, or worse, a civil law suit or referral to his professional regulator for possible professional misconduct. A public authority or business will want to avoid damage to its reputation.

Broadly there are 9 types of conclusion. The most common are natural causes, accident/misadventure, suicide, unlawful killing, lawful killing and an open conclusion. These are examples of the traditional short-form conclusions. In ECHR Article 2 enhanced inquests (“Middleton inquests”) which are much more complex, it is more usual to have a narrative conclusion because the jury is expected to give its findings on the “important” issues that arose. In a standard “Jamieson” style inquest  some coroners were beginning to move away from a short-form conclusion to give a short narrative conclusion instead. This has been affected by the Chief Coroner’s Guidance No 17 (see below). A large body of case law has developed on the subject of conclusions such as when a short form or narrative conclusion can be used, what conclusions can be left to a jury[ R (Bennett) v HM Coroner for Inner London South [2007] EWCA Civ 617, read report R (Lewis) v HM Coroner for Shropshire[2009] EWHC admin 661], read report the standard of proof required for a verdict of unlawful killing [ R v West London Coroner Ex Parte Gray [1988] QB 467]  and the meaning of “neglect” [R v North Humberside Coroner Ex Parte Jamieson [1995] QB1;  R(Middleton) v West Somerset Coroner [2004]UKHL 10 read report

Sometimes as the facts emerge at an inquest it is possible that more than one type of conclusion could be considered. This is where a knowledge and understanding of the relevant case law can be of vital importance. Our lawyers at Inquest Representation Service are familiar with inquest case law and experienced in making submissions on the law to the coroner when the need arises. This is an opportunity to try and influence which conclusion is returned, which can be vital for the person or organisation that is being represented.

Natural causes: As a result of the inquest inquiry the reason for the death is identified as having been due to some natural disease.

Accident/ Misadventure: This can be a genuine accident, for example someone trips whilst carrying a glass bottle and severs an artery on the broken glass when he lands. Or, the death was an unintended consequence of a deliberate action, for example a kite surfer collides with a pier, or a death in hospital unintentionally caused by an operation.

Suicide: the deceased engaged in a deliberate act of self-harm with the specific intention that the action should lead to his death. The evidence must establish this to the criminal standard of proof, beyond reasonable doubt. In certain circumstances the conclusion can be expanded to add “whilst the balance of his mind was disturbed.”

Unlawful Killing: The criminal law definitions of murder and manslaughter are used and the criminal standard of proof applies.  Usually an inquest will have been adjourned to take place after a murder trial. If there is a finding of unlawful killing section 10 (9) of the 2009 Act (previously rule 42) prevents the person from being named in the conclusion. There are 2 types of involuntary manslaughter, unlawful act/ constructive involuntary manslaughter, and gross negligence involuntary manslaughter.

Lawful Killing: Where it is probable that the use of lethal force against the deceased was justified (the person who caused the fatal injury used reasonable force in self-defence, or to prevent a crime, or to assist in a lawful arrest.)

Open Verdict:  There is insufficient evidence to meet the criteria required for any of the other conclusions (for example, the evidence cannot establish suicide “beyond reasonable doubt.”)

Neglect / Self-Neglect Riders: A rider can be added on to the main conclusion of natural causes, accident, suicide (and some of the other conclusions not dealt with here). A neglect rider can be added if  on the balance of probabilities there has been a gross failure to provide food, drink or medicine to a person in a dependent position (due to youth, incarceration, illness or age) But, there has to be proof of a direct causal link. [R v North Humberside Coroner Ex Parte Jamieson [1995] QB1 is the lead case.] Where the deceased contributed to his own death by failure on his part to take adequate nourishment or liquid, or to obtain basic medical attention, or to obtain adequate shelter or heating a rider of self-neglect may be added to the conclusion.

Preferred short form conclusions (as set out in Form 2 of statutory instrument 1616 of 2013)  may include: I: Accident/Misadventure: II: Alcohol/Drug Related; III: Industrial Disease; IV: lawful/unlawful killing; V: natural causes; VI: Open; VII: Road Traffic Collision; VIII: Still Birth; IX: Suicide.

The Chief Coroner has issued Guidance No. 17 : Conclusions: short-form and narrative. This directs that coroners should wherever possible use a short-from conclusion. The guidance emphasises that a narrative conclusion must be a brief, factual,neutral statement that should not express any judgment or opinion.

After all the evidence has been heard or a conclusion has been delivered Section 7 of Schedule 5 of the  2009 Act and Regulations 28 and 29 of the Coroner’s  Investigation Regulations 2013 provides a means for the coroner to make a report to a relevant public authority or person who may be in a position to take appropriate action to avoid a future fatality arising. This is a discretionary power. [These are referred to a PFD reports or Regulation 28 reports] In order to make a PFD report the coroner must assess whether the circumstances of the inquest give rise to the risk of future deaths occurring. Secondly he must make a judgment whether action can or should be taken to prevent those circumstances recurring or continuing, or to eliminate or reduce the risk. Finally he must decide whether or not to make a report. (R (Cairns) v HM Deputy Coroner for Inner West London [2011] EWHC 2890 Admin.) Read the report. The Chief Coroner has issued Guidance No 5: Reports to prevent future deaths (Revised January 2016). For some families of the deceased their aim is to ensure that something may be done to prevent a death in similar circumstances. So obtaining a coroner’s PFD report is extremely important to try and achieve this outcome.  Submissions to the coroner on the family’s behalf can play a vital role in securing a PFD report.

The lawyers at Inquest Representation Service are experienced in dealing with inquests that involve the conclusions discussed and making submissions for and against a PFD report in a range of circumstances.  Our lawyers can advise on whether a particular conclusion is likely to be considered by the coroner.  Our lawyers provide inquest law legal advice and representation in relation to inquests all over England and Wales. Please call 033 00 77 00 97 to enquire how the Inquest Representation Service might be able to assist you.  The lawyers at the Inquest Representation Service are regulated by the legal regulator the Bar Standards Board.