Summary
From short-form conclusions like “accident or misadventure” or “natural causes,” to more detailed narrative conclusions, the findings from an inquest can shape public perception, prompt regulatory investigation, or even lead to further legal action. In some cases, neglect may be identified, and while rare, its implications can be significant.
This article explains the full range of possible outcomes at the end of an inquest, how each type of conclusion works, and why understanding them matters.
What Conclusions Can a Coroner Reach?
At the end of an inquest, the coroner can reach a number of findings and conclusions. All conclusions are established on the balance of probabilities. In other words, the coroner must be satisfied that it’s more likely than not that the events happened in the way they describe.
Short-form conclusions are typically just one or two words and include standard phrases such as:
- Accident or misadventure
- Alcohol or drugs-related death
- Unlawful or lawful killing
- Suicide
- Stillbirth
- Industrial disease
- Road traffic collision
- Natural causes
- Open conclusion
In some cases, the conclusion may be left “open” which is when there isn’t enough evidence to return one of the other conclusions. Open conclusions are relatively rare and generally discouraged. In most cases, it’s preferable for the coroner to provide a narrative setting out what findings have or haven’t been made.
Findings of Neglect
While neglect is not a standalone conclusion, the words “contributed to by neglect” can be added to a short-form or narrative conclusion in some circumstances.
For this to happen, the coroner must be satisfied that:
- There was a gross failure to provide basic medical attention to someone in a dependent position
- There is a clear and direct causal connection between the conduct described as neglect and the cause of death
- The conduct contributed to the death in a way that was more than minimal, trivial or negligible
It’s not enough to show that there was a missed opportunity to provide care that might have made a difference – the threshold is high (it must be shown that care should have been rendered and that it would have saved or prolonged life), and findings of neglect are relatively rare.
Narrative Conclusions
A narrative conclusion is more descriptive than other conclusions. It usually takes the form of a paragraph or two, outlining the key circumstances of the death. Narrative conclusions are often more helpful and preferred by families.
Narrative conclusions can include references to neglect if the coroner feels it’s appropriate. However, the narrative will focus on the central issues and does not need to cover every point raised during the inquest process.
Inquests Leading to Further Legal or Regulatory Action
Inquests can in fact lead to other legal or regulatory steps. For example, the Care Quality Commission (CQC) often attends inquests involving registered providers. They use the process to gather insight and listen to evidence – and may later rely on what they’ve heard to support a prosecution against a provider if they identify any prosecutable regulatory breaches.
Similarly, the findings of an inquest can prompt civil claims by families against companies or individuals, depending on what is revealed during the proceedings.
Can a Coroner Ever Assign Blame?
Coroners are not permitted to assign blame or legal fault. Inquests are inquisitorial processes, not adversarial. Coroners can sometimes stray into that territory but it is very rare – and when it happens, it should be raised and addressed appropriately.
However, coroners can raise concerns about matters that arise during an inquest investigation through the issuance of Regulation 28 reports, more commonly known as Prevention of Future Death reports (PFDs). When investigating a death, if anything is revealed by the investigation that gives rise to a concern that circumstances creating a risk of other deaths will occur or continue to exist, and the coroner is of the opinion that action needs to be taken to address this, they have a duty to issue a PFD. PFD’s will be sent to any person (including organisations) the coroner believes may have power to take action and the recipients will be named in the PFD. While PFDs should not be interpreted as an assignment of blame, they can have a reputational impact on their recipients, particularly considering most PFDs are now published.
Conclusion
The outcome of an inquest can have a lasting impact, not just on the public record, but on how an organisation is perceived, regulated, or even legally challenged. Understanding the types of conclusions a coroner can reach, including findings of neglect or narrative explanations, helps providers prepare, respond, and protect their position.
At Gordons Partnership, we support clients through every stage of the inquest process, ensuring they’re not only heard but understood. If you’re facing an inquest or concerned about the potential implications of one, we’re here to help you navigate it with clarity, care and confidence.
About the Author
Senior Associate Solicitor
Tel: 01483 451 900