Inquest conclusions explained
When a person dies unexpectedly, it can be beneficial for families and authorities to have answers about what happened. An inquest conclusion can help provide these answers – whether it’s confirming an accident, a suicide or an unlawful killing.
An inquest is a judicial process that takes place in a court of law. Unlike other legal hearings, an inquest is an inquiry not a trial, which means it is generally a fact-finding not a fault-finding process.
As a result, an inquest comes to conclusions rather than verdicts. A conclusion will either be given by the Coroner, who oversees the inquest process, or by a jury following direction from the Coroner.
Common short form conclusions
An inquest conclusion is based on the evidence presented about how, when and where a person died. According to the Ministry of Justice, 39,600 inquest conclusions were recorded in England and Wales in 2024. The majority of these inquests involved one of the standard short form conclusions, which include the following:
- Natural causes: the death was caused by the normal progression of a natural illness without any significant human intervention.
- Suicide: when, on the balance of probabilities, a person died following a deliberate act initiated by themselves and that their intention was to cause to death.
- Road traffic collision: the deceased suffered fatal injuries, whether as a driver, passenger or pedestrian while on a public highway.
- Accident or misadventure: an unexpected event, which was neither intended nor envisaged, resulting in death.
- Unlawful killing: when murder, infanticide or manslaughter (including gross negligence manslaughter and corporate manslaughter) are determined as the cause of death.
- Lawful killing: the death of the deceased resulted from an action justified in law, such as self-defence.
There are also specific short form conclusions that relate to industrial disease, the misuse of drugs or alcohol, and stillborn babies.
Open and narrative conclusions
Coroners and juries are not restricted when it comes to giving conclusions or making recommendations. For example, in more complex cases where the cause of death could involve multiple factors, a Coroner or jury might decide on an open or narrative conclusion.
An open conclusion is recorded when there is insufficient evidence to support one of the short form conclusions. This outcome, however, is becoming increasingly rare: according to the Ministry of Justice, 3% of inquests in England and Wales resulted in an open conclusion in 2024 compared with 6% in 2014.
A narrative conclusion is relevant when a more detailed conclusion needs to be given to explain the cause of death. For example, there might be extenuating circumstances to consider, failings to highlight or lessons to learn.
As part of the conclusion, the coroner might make specific recommendations to prevent similar fatalities in the future and notify relevant authorities, for example an NHS Trust following the avoidable death of a patient.
Inquest conclusions and recommendations can prompt subsequent civil or criminal cases, such as a medical negligence claim or a murder investigation.
If you’re participating in an inquest and want to know more about the process and the different potential outcomes, then please get in touch with our team.
