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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.
What it means: Death resulted from disease or natural deterioration of bodily functions without external cause.
Common examples:
Note: Even when death occurred in hospital or during medical treatment, if it resulted from natural disease progression, the conclusion is natural causes.
What it means: Death resulted from an unintended event or consequence of a lawful act.
Common examples:
"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).
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:
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.
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:
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.
What it means: Killing was justified and lawful (e.g., in self-defence or military action).
Extremely rare. Used in specific circumstances like:
What it means: Insufficient evidence to determine how death occurred with certainty.
When it's used:
Example: Found drowned, but unknown whether accidental fall, suicide, or unlawful killing.
What it means: Death resulted from a disease contracted through employment.
Common examples:
What it means: Death was directly caused by the effects of drugs or alcohol.
May be combined with:
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.
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:
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.
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."
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.
Every conclusion is decided to the same standard:
The conclusion is determined by:
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:
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.
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.
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:
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.
If you believe the conclusion was legally wrong:
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:
This is the medical condition that directly caused death, recorded in standard format:
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:
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.
An unlawful killing conclusion may support criminal prosecution, but doesn't guarantee it. The Crown Prosecution Service makes independent charging decisions.
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 bodies (GMC, NMC, etc.) may investigate based on inquest findings, but make independent decisions about professional conduct.
The Health and Safety Executive may prosecute employers based on inquest findings, particularly if an accident conclusion reveals workplace safety failures.
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 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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