Understanding Conclusions, Disclosure, and Family Expectations of Coroner’s Inquests

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In the United Kingdom, coroner’s inquests serve as vital mechanisms for investigating the circumstances surrounding unexpected deaths. These inquiries, presided over by a coroner, can often establish vital information about how somebody came by their death, as well as providing closure for the deceased’s family, and, where necessary, recommendations aimed at preventing future deaths. However, the process is not without its complexities. Below, we will explore the potential conclusions a coroner can reach, the practical issues related to disclosure, and the delicate balance of managing family expectations, particularly when considering the coroner’s requirement to operate within the framework of the statutory questions they are required to answer.

Understanding Coroner’s Conclusions

Coroners are tasked under Section 5 of the Coroners and Justice Act 2009 with answering specific statutory questions when investigating a death. These questions are who the deceased was, when and where they died, and how they came about their death. Following the inquest the Coroner will give a conclusion, and there are various conclusions which the Coroner can reach. Conclusions can be either short form or narrative conclusions. Some short form conclusions relevant to the clinical context can include:

Short Form Conclusions

  1. Natural Causes: If the death occurred due to natural causes, the coroner can conclude that the deceased passed away from a medical condition without any external factors contributing significantly.
  1. Accidental Death: This conclusion is drawn when the death was unintentional and resulted from unforeseen events or accidents.
  1. Suicide: When the evidence indicates that the deceased took their own life, the coroner can conclude suicide. This conclusion requires careful consideration and sensitivity due to its profound impact on the deceased’s family.
  1. Unlawful Killing: If the death resulted from a criminal act, the coroner can conclude unlawful killing. This finding can lead to criminal investigations and legal proceedings.
  1. Open Conclusion: In cases where the evidence does not clearly support any of the above conclusions, the coroner may deliver an open conclusion, signifying that the circumstances surrounding the death remain unclear.

There are other short form conclusions available to a coroner including accident or misadventure, alcohol or drug related death, industrial disease and road traffic collision.

Narrative Conclusions

In some circumstances, and in many cases in which we are instructed to represent families, the coroner may determine that a narrative conclusion is better than a short-form conclusion. A narrative will give the coroner (or jury) the opportunity to state what findings are made and what are not. Or alternatively, an open conclusion can have extra words appended by way of explanation.

Importantly though, coroners are encouraged to keep narrative conclusions short, and are strongly discouraged from including “expressions suggestive of civil liability, in particular ‘neglect’ or ‘carelessness’” (see R (Middleton) v West Somerset Coroner and another [2004]).


We are often instructed by families who feel that their loved one has passed away as a result of negligent medical care or negligence whilst they were resident in a care home. Coroners are entitled to return a conclusion with a rider of neglect, however in order to be able to do this, the coroner must be satisfied that the deceased was in a dependent position and that as a matter of law there is evidence of a ‘gross failure’, and that there was a clear connection between the gross failure and the death.

Findings of neglect are often very difficult to achieve at the conclusion of an inquest. It is helpful to consider the court’s definition of ‘neglect’ in the case of R v HM Coroner of North Humberside and Scunthorpe Ex p Jamieson [1995], which perhaps goes some way towards showing the limited scope of this definiteion, and in explaining why such findings are rare in practice:

Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide or procure basic medical attention or shelter or warmth for someone in a dependent position – because of youth, age, illness or incarceration – who cannot provide it for himself. Failure to provide medical attention for a dependent person whose physical condition is such as to show that he obviously needs it may amount to neglect…

Standard of Proof

The standard required for the coroner to reach a conclusion is the civil standard of proof (i.e. ‘on the balance of probabilites’) as opposed to the more burdensome criminal burden of proof (‘beyond reasonable doubt’).

Interestingly, until very recently if a coroner was to make a finding of suicide or unlawful killing, then they were required to apply the criminal standard of proof. However, this changed following the Supreme Court’s consideration and determination of these issues in the case of R (on the application of Maughan) v. Her Majesty’s Senior Coroner for Oxfordshire [2020] UKSC 46, in which the court held that the civil standard of proof applied to both suicide and unlawful killing. Whilst this arguably creates more certainty and consistency with the requirements for other conclusions, it has not been without its opponents.

On a more practical basis, there are other important considerations which should be borne in mind when preparing for and attending inquests.


One of the most significant challenges in coronial inquests revolves around the disclosure of documentation. Despite coroners often setting clear dates for disclosure of material, these dates are often not complied with, particularly when dealing with large hospitals for example. Paragraph 1 of Schedule 5 to the Coroners and Justice Act 2009 gives a coroner the power, by way of a written notice, to compel the production of evidence for the purposes of an investigation however, and is something which can be considered where important disclosure is not forthcoming.

Balancing the need for transparency within the relevant timeframes with the sensitivity of the situation is crucial. Recently, we have noticed that late disclosure has led to significant issues for us and the families we represent. In some instances new information has come to light just days (and in some cases hours) prior to the start of the inquest. This not only leads to problems in preparing for the inquest and advising our clients, but has the potential to prevent them and other interested parties from participating fully and properly in the inquest process. This in turn raises concerns regarding transparency and accountability in such cases.

The timing of disclosure can also impact on the parties at the stage of Pre-Inquest Review hearings. If parties are able to go into these hearings having had full disclosure of all relevant documentation which is available at that stage, then they are then more fully able to prepare for the hearing, and to address the agenda on a more informed basis.

Addressing this issue is critical for ensuring a fair and effective inquest process, as well as upholding the principles of justice and accountability.

Family Expectations

Families often have high expectations for inquests, often seeking detailed explanations and thorough investigations, which can often clash with the legal limitations which are placed on coroners by the statutory rules mentioned previously. It is important to be aware that a coroner’s inquest is an inquisitorial process and the scope of the inquest is under the control of the coroner. It is not an adversarial process, and whilst often people who were involved in, or responsible for, the Deceased’s care will give evidence, it is not a trial. The purpose of an inquest is not to establish liability or to impart blame on any given person or organisation.

Coroners and legal representatives must navigate the challenge of managing families’ expectations with empathy, ensuring that they are informed about the progress of the investigation, while respecting legal boundaries. Managing these expectations is an intricate process that requires clear communication and compassion.


Coroner’s inquests in the UK play a pivotal role in understanding unexpected deaths, providing closure to families, and ensuring that lessons are learned to prevent future deaths. Navigating the complexities of coronial conclusions, disclosure, and managing family expectations requires a delicate balance of legal expertise, empathy, and open communication.

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