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A conclusion is the coroner's or jury's overarching explanation of how someone died. Section 5(1) of the Coroners and Justice Act 2009 sets the questions an inquest exists to answer: who the deceased was, and how, when and where they came by their death. Section 10(2) sets the limit — the determination may not be framed so as to appear to determine any question of criminal liability on the part of a named person, or any civil liability.
The Ministry of Justice lists ten short-form conclusions: accident or misadventure, alcohol/drug related, industrial disease, lawful killing, unlawful killing, natural causes, open, road traffic collision, stillbirth and suicide. A coroner or jury can also give a brief narrative conclusion instead of, or alongside, one of these.
1. Natural Causes
What it means: Death resulted from disease or natural deterioration of bodily functions without external cause.
Common examples:
- Heart attack or stroke
- Cancer
- Pneumonia or other infections
- Organ failure from chronic disease
- Age-related decline
Note: Even when death occurred in hospital or during medical treatment, if it resulted from natural disease progression, the conclusion is natural causes.
2. Accident or Misadventure
What it means: Death resulted from an unintended event or consequence of a lawful act.
Common examples:
- Road traffic accidents
- Falls resulting in fatal injury
- Accidental drowning
- Industrial accidents
- Accidental poisoning or overdose
- Complications from medical procedures (when procedure was appropriate)
"Misadventure" is used when the deceased contributed to their own death through their actions, but without intent (e.g., taking medication that caused unexpected fatal reaction).
3. Suicide
What it means: The deceased intentionally took their own life.
Standard of proof: the balance of probabilities. In R (Maughan) v HM Senior Coroner for Oxfordshire [2020] UKSC 46 the Supreme Court held that the civil standard applies to suicide, and the note in the Record of Inquest form that had set out the standard of proof was removed on 12 January 2022. Older guidance saying suicide must be proved beyond reasonable doubt is wrong.
What has to be shown:
- That the person took their own life
- That they intended to do so
- Both on the balance of probabilities, on the evidence given at the inquest
Suicide was the second most common short-form conclusion in 2025: 5,298 conclusions, 14% of the total, and the highest number since the series began in 1995.
4. Unlawful Killing
What it means: Death resulted from murder, manslaughter, or infanticide.
Standard of proof: the balance of probabilities, following R (Maughan). The Supreme Court's reasoning applied to unlawful killing as well as suicide.
When it's used:
- Clear evidence someone unlawfully caused the death
- Usually follows or runs parallel to criminal proceedings
- Doesn't name individuals (that's for criminal courts)
Where a person is charged with an offence connected to the death, Schedule 1 to the Coroners and Justice Act 2009 requires the investigation to be suspended. In 2025, 793 investigations were suspended and not resumed because the criminal proceedings had answered the statutory questions.
5. Lawful Killing
What it means: Killing was justified and lawful (e.g., in self-defence or military action).
Extremely rare. Used in specific circumstances like:
- Deaths in military action
- Police shootings deemed justified
- Lawful self-defence by third parties
6. Open Verdict (Open Conclusion)
What it means: Insufficient evidence to determine how death occurred with certainty.
When it's used:
- Cannot rule between accident and suicide
- Unclear circumstances with multiple possibilities
- Insufficient evidence for definitive conclusion
- Known cause of death but unknown how it came about
Example: Found drowned, but unknown whether accidental fall, suicide, or unlawful killing.
7. Industrial Disease
What it means: Death resulted from a disease contracted through employment.
Common examples:
- Asbestosis or mesothelioma
- Pneumoconiosis (coal workers' lung disease)
- Other occupational diseases
8. Drug/Alcohol Related
What it means: Death was directly caused by the effects of drugs or alcohol.
May be combined with:
- "Drug-related death" (overdose, whether intentional or accidental)
- "Alcohol-related death"
- Often accompanied by narrative to explain context
9. Stillbirth
What it means: Baby born dead after 24 weeks of pregnancy.
Stillbirths after 24 weeks are registered as stillbirths, not deaths. Inquests only occur if there are concerning circumstances.
10. Died from Want of Attention at Birth
What it means: Death of newborn due to lack of proper care during birth.
Very rare in modern practice due to improved maternity care.
Increasingly common, narrative conclusions provide a more detailed explanation:
What is a Narrative Conclusion?
A narrative conclusion is a brief statement describing the circumstances of death in more detail than a short-form conclusion allows. It can be used alone or with a short-form conclusion.
When Narrative Conclusions Are Used
- Complex deaths involving multiple factors
- When a short-form conclusion is too simplistic
- To highlight systemic issues or failures
- To provide more meaningful explanation to families
- In Article 2 (state duty) inquests
Example Narrative Conclusions
Example 1 (Medical setting):
"Mr. Smith died from complications of surgery to repair an abdominal aortic aneurysm. Contributing factors included delayed recognition of post-operative bleeding and insufficient critical care capacity at the hospital on that date."
Example 2 (Mental health):
"Ms. Jones died by hanging following discharge from psychiatric services. She had expressed suicidal ideation but risk assessment was inadequate and follow-up appointments were not provided."
Example 3 (Custody death):
"Mr. Brown died from acute drug toxicity while in prison. Prison staff failed to identify withdrawal symptoms and did not provide adequate medical monitoring despite known substance abuse history."
Why Families Often Prefer Narrative Conclusions
Narrative conclusions can capture nuance that short-form conclusions miss, acknowledge systemic failures, and provide a fuller understanding of what happened. They often feel more meaningful to bereaved families.
Standard of Proof
Every conclusion is decided to the same standard:
- One standard, for everything: the balance of probabilities
- Until 2020 the criminal standard was understood to apply to suicide and unlawful killing. The Supreme Court held otherwise in R (Maughan) v HM Senior Coroner for Oxfordshire [2020] UKSC 46
- The Coroners (Inquests) (Amendment) Rules 2021 then removed the standard-of-proof note from the Record of Inquest form with effect from 12 January 2022
Who Decides
The conclusion is determined by:
- The coroner: In most inquests
- The jury: section 7(2) of the Coroners and Justice Act 2009 requires a jury where the coroner has reason to suspect a violent or unnatural death, or a death of unknown cause, in custody or other state detention; a death resulting from an act or omission of a police officer or service police officer in the purported execution of their duty; or a death caused by a notifiable accident, poisoning or disease. A coroner may also sit with a jury where they think there is sufficient reason. In 2025, 527 inquests — 1% — were held with juries
Coroner's Summing Up
At the end of evidence, the coroner summarizes the case and explains what conclusions are legally available. For jury inquests, the jury must choose from the options the coroner identifies as legally possible.
It's important to understand the limitations:
Don't Determine Guilt: Conclusions don't name individuals as criminally or civilly liable. That's for criminal or civil courts.
Don't Award Compensation: Inquests don't provide financial compensation. That requires separate civil litigation.
Don't Impose Penalties: Inquests don't punish individuals or organizations. Regulatory bodies or criminal courts handle that.
Don't Always Answer "Why": Inquests establish how someone died (the medical cause and circumstances) but can't always explain why in a deeper sense.
Separately from the conclusion, the coroner may issue a Prevention of Future Deaths (PFD) report:
What is a PFD Report?
Where the coroner's investigation raises a concern that action should be taken to prevent future deaths, paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 requires them to report it to the people or organisations able to take that action. In 2025, 654 such reports were issued — 2% of inquests concluded.
Who Receives PFD Reports?
- Hospitals or NHS trusts
- Government departments
- Local authorities
- Private companies
- Professional regulatory bodies
- Any organization with power to take preventative action
Responses Required
Regulation 29 of the Coroners (Investigations) Regulations 2013 requires the response to be provided to the coroner within 56 days of the date the report is sent, setting out what action has been or will be taken and a timetable, or explaining why no action is proposed. The coroner may extend that period. Copies of reports and responses go to the Chief Coroner and to interested persons the coroner thinks should receive them, and the Chief Coroner may publish them.
Relationship to Conclusion
PFD reports are independent of the conclusion. A natural causes conclusion doesn't prevent a PFD report if systemic issues are identified.
If you disagree with the conclusion:
Making Submissions
Before the coroner or jury reaches a conclusion, you (or your lawyer) can make submissions about what conclusion is appropriate and legally available. This is your opportunity to argue for a particular outcome.
Challenging After the Inquest
If you believe the conclusion was legally wrong:
- Ask the Attorney General for authority to apply to the High Court under section 13 of the Coroners Act 1988
- The court can order a fresh investigation where it is satisfied the coroner refuses or neglects to hold one that ought to be held, or that (by fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, the discovery of new facts or evidence, or otherwise) a further investigation is necessary or desirable in the interests of justice
- The court may also quash the determination or finding made at the earlier inquest
- No official statistics are published on how many section 13 applications succeed
Judicial Review
Judicial review is a separate route to a section 13 application, with a different test. It is a challenge in the High Court to the lawfulness of a coroner's decision or the way an inquest was conducted — including, in principle, a conclusion that no reasonable coroner could have reached. A claim must be brought promptly and in any event within three months of the decision. Our guide to challenging coroner decisions goes through both routes.
The conclusion is separate from the medical cause of death:
Medical Cause
This is the medical condition that directly caused death, recorded in standard format:
- 1a: Immediate cause (e.g., "cardiac arrest")
- 1b: Underlying cause (e.g., "myocardial infarction")
- 1c: Further underlying cause (e.g., "coronary artery disease")
- 2: Other significant conditions (e.g., "diabetes mellitus")
Conclusion
This describes how the person came to die in those circumstances (natural causes, accident, suicide, etc.). Same medical cause can have different conclusions depending on circumstances.
After the inquest, you'll receive a Record of Inquest:
What It Contains
- Who died, when and where
- The conclusion reached
- The medical cause of death
- Coroner's signature and date
What It's Used For
- Registering the death (if not already registered)
- Estate administration
- Insurance claims
- Civil litigation
- Regulatory proceedings
Getting Copies
No published fee scale exists for copies of a Record of Inquest, and practice varies between coroner areas. Ask the coroner's office what they provide and whether they charge.
Criminal Proceedings
An unlawful killing conclusion may support criminal prosecution, but doesn't guarantee it. The Crown Prosecution Service makes independent charging decisions.
Civil Claims
Inquest findings can be used in civil litigation but aren't binding. You'll still need to prove your case to civil standard in a civil court.
Professional Regulation
Professional bodies (GMC, NMC, etc.) may investigate based on inquest findings, but make independent decisions about professional conduct.
Health and Safety Prosecution
The Health and Safety Executive may prosecute employers based on inquest findings, particularly if an accident conclusion reveals workplace safety failures.
Scotland
Scotland has no coroners and no inquests. Deaths are reported to the Procurator Fiscal, and where a public inquiry is held it is a Fatal Accident Inquiry in the sheriff court under the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016. The sheriff issues a determination, which is not a conclusion in the sense used on this page — none of the short-form conclusions above apply in Scotland, and neither do the MoJ statistics.
Northern Ireland
Northern Ireland has coroners, but a different legal framework: the Coroners Act (Northern Ireland) 1959, not the Coroners and Justice Act 2009. The statutory provisions and rules cited on this page apply to England and Wales only, and the MoJ statistics cover England and Wales only.
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