How coroners arrive at their conclusions

In the last of this three-part series explaining how the inquest process relates to independent practitioners, Thorrun Govind explains inquest conclusions and what they mean.

Record of Inquest

For simplicity, I will be referring to inquests without a jury in this article. A jury will not be present for the majority of inquests. 

The coroner’s final role upon hearing the evidence is to complete the Record of Inquest. This includes:

  • Box 1 – Name of the deceased;
  • Box 2 – Medical cause of death;
  • Box 3 – How, when and where – and for investigations where section 5(2) of the Coroner’s and Justice Act 2009 applies, ‘in what circumstances’ – the deceased came by their death.
  • Box 4 – Conclusion of the coroner;
  • Box 5 – Further particulars required by the Birth and Deaths Registration Act 1953 to be registered concerning the death; for example, date and place of death, name and surname of the deceased, sex, maiden name for a woman who has married, date and place of birth, occupation and usual address.

Box 1 and Box 5 – Particulars to the individual

These are often established prior to the inquest and do not require much investigation by the coroner.

Box 2 – Medical cause of death

With consideration to post mortem evidence, if available, or from witness evidence, the coroner will be able to finalise this for the Record of Inquest. 

The formulation is based on World Health Organization recommendations:

  • 1 a) Disease or condition leading directly to death;
  • 1 b) Other disease or condition, if any, leading to 1(a);
  • 1 c) Other disease or condition, if any, leading to 1(b);
  • 2 Other significant conditions contributing to death but not related to the disease or condition causing it.

Box 4 – Conclusion of the coroner

This is the stage that requires most coronial input. The Coroner’s Court is a fact-finding inquiry reaching a conclusion and not an adversarial trial with a verdict. 

Conclusions used to be called verdicts. However, in 2013, coronial law changed this to reflect the non-adversarial nature; though they are often still labelled as this incorrectly in the press.

Legal representatives present in court can make submissions about which conclusion(s) the coroner should consider. Coroners are reminded by the Chief Coroner’s Guidance that they should at all times use moderate, neutral and well-tempered language, befitting the holder of a judicial office. 

The coroner is required, having heard the evidence, and in addition to deciding the medical cause of death, to arrive at a conclusion by way of a three-stage process. It is important to remember that it may take some time for the coroner to reach their decision.

1. To make findings of fact based upon the evidence.

The coroner will state the key findings of the evidence that they have heard. In doing so, they work to the civil standard of ‘on the balance of probability’.

2. To distil from these findings of fact ‘how’ – in other words, by what means – the deceased came by their death.

This will usually be a description of the mechanism of death such as ‘by drowning while swimming in the open sea’.

3. To distil from the above findings of fact as to ‘how’ the deceased came by their death and to record that briefly in Box 3 of the Record of Inquest.

The coroner will add to the wording at point 2 above, the date and place of death, where known, and, where necessary, a brief description to expand upon how the deceased came by their death.


The conclusion – which is placed in ‘Box 4’ of the Record of Inquest – will either be what is known as a ‘short-form’ conclusion or a narrative conclusion.

Short Form – for example, natural causes, suicide, industrial disease, alcohol/drug-related, accident/misadventure, open;

Natural causes – This is considered be the normal progression of a natural disease or illness, where a naturally recurring disease runs its full course without any significant amount of medical care or human intervention;

Suicide – This is defined as a deliberate act by the deceased and that the intended consequence of this act was, at all times, to be death;

Industrial disease – when the death resulted from a disease caused by work;

Alcohol/drug-related – this can cover an accidental death resulting from abuse of alcohol or drugs or from the result of being addicted to alcohol/drugs;

Accident/misadventure – an unnatural event which was neither unlawful nor intended by the deceased to result in death. 

This may therefore be appropriate where medical treatment caused the death. Accident or misadventure can be used interchangeably;

Open – This is used when none of the other verdicts are appropriate and the evidence does not fully explain the cause and circumstances of death;

Narrative – As an ‘alternative’ to a short-form conclusion, the coroner may record a ‘brief narrative conclusion’ which goes into more detail regarding the factual findings.

The coroner also has the ability to return a conclusion which includes a rider of neglect, and the case of R v HM Coroner of North Humberside and Scunthorpe Ex p Jamieson [1995] is the authority. 

For this, the court must be satisfied that the deceased was in a dependent position and that legally there is evidence of a gross failure of basic medical care which should obviously have been provided. 

There must be a clear and direct causal connection between the gross failure and the death for neglect to be applied; for example, a nurse failing to provide antibiotics to a patient for a day despite them being prescribed. 

The patient in this case would be obviously in need and deteriorating and this omission would have to directly cause the death.

For an introduction to the inquest process, see our previous articles in Independent Practitioner Today: ‘When you’re asked to go to an inquest’ and ‘What happens when you’re called to an inquest?’.

First published in Independent Practitioner Today in October2022.