What verdicts can the inquest return?
There are a number of verdicts that can be given including:
- • 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 (which means almost the same thing);
• disaster which is the subject of a public inquiry;
• attempted or self-induced abortion;
• lawful killing;
• unlawful killing;
• open verdict – this means that the cause of death cannot be established and doubt remains as to how the deceased came to their death;
• stillbirth;
• narrative verdict.
In some cases the words “contributed to by neglect” can be added, but the law is very limited on when this can be applied and neglect does not mean the same in law as it does in everyday language. “Systemic neglect” can also be considered in some circumstances where evidence showed that insufficient action was taken to prevent a death.
All of these verdicts have to be established to the test within the balance of probabilities except for suicide and unlawful killing, which have to be proved beyond reasonable doubt.
When does the coroner use the verdict ‘killed him or herself’?
When it is believed, on the basis of the factual evidence that the person genuinely intended to kill themselves. For this verdict to be returned there has to be clear evidence, for example a suicide note, which shows beyond reasonable doubt that it was definitely the person’s intention to take their own life. If they did something that resulted in their death but there is not enough evidence that they intended to die, then this verdict cannot be returned.
What verdict is used if there is insufficient evidence that somebody had intended to kill themselves?
Misadventure, accidental death or an open verdict.
Would the verdict ‘killed him or herself’ have to be supported by a suicide note?
No, but that is a piece of evidence which could show intent.
What do accidental death and misadventure mean?
Accidental death means that the person died as a result of actions by themselves or others that had unintended consequences.
Misadventure is similar to accident but means that the deceased or others were carrying out an intended action (for example a planned surgical operation) but there was an unintended outcome (in this example, the death of the patient).
What does an open verdict mean?
This means that there is not enough evidence to return any other verdict.
What does unlawful killing mean?
This verdict means that the person was killed by an ‘unlawful act’ by someone or some others or as the result of their ‘gross negligence.’ These are both legal terms that are clearly defined in the criminal law. Unlawful killing is a very rare verdict.
If I think an institution (such as a prison or hospital) has neglected my relative, will that be included in the verdict?
There is a real difference between the meaning of ‘neglect’ in common speech and what that means in law. This is a complicated area and you should discuss this with your solicitor or one of the organisations on the links page. As indicated above, it is rare for the words “contributed to by neglect” to be added to one of the verdicts already mentioned. The verdict cannot state that any individual is guilty of neglect.
What is a narrative verdict?
In some circumstances, particularly in inquests where article 2 of the European Convention on Human Rights applies (see Section 1.3: What is an inquest?), the jury can be asked to provide a narrative verdict. This allows the jury to expand on their verdict and give a longer explanation of what they think the main or important issues are. If you are legally represented, it is important to discuss this with your solicitor or barrister.
A narrative verdict can be a very powerful way of exposing any problems or mistakes that have been made, even though it will still not name any individuals as being to blame. If there are any disputes about what happened factually which are important, the narrative can include the jury’s decision on those facts. The jury should record any failings if these caused or contributed to the death.
Can the coroner make recommendations to prevent a further death occurring in similar circumstances?
The coroner has an important role in trying to prevent further deaths and under rule 43 of the Coroners Rules 1984, after the verdict the coroner may announce that they will write to any person or authority that has the power to take action to prevent future deaths.
This is referred to as a rule 43 report. The coroner is the only person entitled to make any comment in court after the verdict. Some coroners will allow lawyers to suggest things they think should be considered under rule 43.
Can the jury make any recommendations?
No. But as explained above in some circumstances they can write a narrative verdict including their concerns as long as they do not criticise a named individual.
Can the coroner’s recommendations be enforced and will I find out what response they received?
No. The relevant person or organisation is not under any obligation to act on the coroner’s recommendations, but under new rules introduced in the Coroners (Amendment) Rules 2008, they must reply within 56 days. The response should give details of any actions that have been taken, actions that will be taken, or explain why no action is going to be taken. The coroner must share these reports and any responses with any properly interested persons (which includes the family) and with the Lord Chancellor.
How does the inquest finish?
The coroner and jury (if there is one) sign a document (Form 22, known as the inquisition) giving the findings of the inquest, which records the answers to the questions: who the person was, where they died, when they died, and how, i.e. the medical cause of death. You should be given a copy of this form.
