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20 July 2014

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7. The Coroner's verdict

In Post #6 I have already talked about a bit about a Coroner's inquest - when it is necessary. I think it is a good idea to look at Coroner's verdicts a bit more in detail.

Firstly, a Coroner's inquest is, of course, very different from a criminal trial. There is no prosecution and no defence, and with the verdict, no one is going to be found 'guilty' or 'not guilty'. The verdict should contain exactly the answers to the 4 questions the Coroner has to establish: Who died, When did they die, Where did they die, How did they die. And also the 'short term' verdict - and this is what people commonly know and refer to as 'the verdict'.

Some common short-term verdicts:

  • Natural Causes
If a naturally occurring disease is responsible for the death rather than any outside influences. 

example 1: if someone died during an operation, but the evidence shows that the natural disease (i.e. heart disease) was so severe that the person died from this rather than anything which went 'wrong' during the operation. 

example 2: a body is found decomposed and the pathologist could not establish a cause of death, but records from doctors show that the person had a very serious disease and was likely going to die and there is nothing to show that anything else (accident, suicide) happened.

  • Drug and/or alcohol related
These are usually what is commonly thought of as overdoses or if a person has a very high alcohol level in him/her and there are no other reasons why the person could have died. Usually, these kind of verdicts are based on toxicology testing

  • Accident
This covers all kind of different accidents such as road traffic accident, accidents in the house, falls down stairs, falls in the road, auto-erotic, on the railway, accidents at work.

  • Suicide / Took his/her own life / Killed him/herself whilst the balance of his/her mind was disturbed
This death could have been by different means such as hanging, overdoses, shooting oneself, on the railway. 
This verdict has a very strong legal requirement of proof - beyond reasonable doubt. So, if the Coroner even has the slightest doubt that the person intended to take their own life, they should not record a verdict of suicide. Usually, the 'proof' the Coroner is looking for is a recent 'suicide note' where the person states that they intend to take their own life. The reasons for this don't matter too much to the Coroner (though they obviously matter a lot to the one's left behind!).
Killed him/herself whilst the balance of his/her ind was disturbed could mean that the person was know to have so kind of mental health issues already.

  • Unlawfully killed
Those are the murder cases. I will talk in a separate post about murders. Briefly, if a person has been charged and brought before a court, usually there would not be a Coroner's hearing. A Coroner only hears a murder case if no-one has been brought before a criminal court.

  • Lawfully killed
Quite a rare verdict. I can only think of one example I've ever heard of and that was of a person who was shot dead by police after he was threatening the public with a gun.

  • Industrial Disease
The most common one of those is Asbestosis. It means that the person died as a result of a disease he/she contracted whilst being exposed to at work. It could also be, for example, if the wife of a person died who was washing his clothes which were covered in asbestos dust. 

  • Open verdict
This verdict is most often mis-understood. Open verdict does not mean that the case is going to continue. It is closed after the verdict 'open' has been delivered and not going to continue. Open verdict quite simply means that the Coroner has no evidence one way or another what has happened to the person.

Example 1: decomposed body, no evidence what could have happened (pathologist can't state the cause of death, no medical history or the medical history is not sufficient to convince the Coroner the person died from natural disease), no evidence of accident, no evidence of suicide.

Example 2: a person has taken on overdose of tablets, but the evidence is not enough to suggest whether the person wanted to take their own life or whether it was an accident.

This verdict is sometimes very difficult for families, as it does not really give them the closure they are so often looking for. But the Coroner can only go by the evidence available to him/her.

  • Narrative verdict
If the Coroner feels that the verdict he/she wants to give does not fit any of the short term verdicts, he/she can quite simply record a text as the verdict. I've seen those verdicts quite often if the circumstances are too complicated for a simple verdict.

Mrs Bloogs had severe heart disease. On 2 March 2014 she had a fall in the nursing home and was admitted to hospital with a fractured pelvis. Surgery was complicated and her mental state was as such that she did not easily accept medical treatment and refused medication. 

= all this text above is the verdict.

There are a few more obscure ones which I haven't mentioned. Than there is the Neglect  verdict which the Coroner can also add on to other verdicts.

One example would be:
Natural causes contributed to by neglect.
(a person who has terminal cancer but was not send for treatment for whatever reason).


So, what does a Coroner's verdict mean? As I said before, this is not a prosecution, and a Coroner's verdict is quite simply to record the circumstances of a death. The Coroner cannot name an individual or a person as being responsible for the death.

The Coroner will not instigate negligence claims etc, that will be up to the family. But, of course, a Coroner's verdict may assist the family in a negligence claim.


The Coroner can do what is called a 'Prevention of Future Deaths' letter after an inquest. Again, this is not to blame / shame an individual. It is done if, during the inquest, the Coroner uncovers maybe certain practices or issues which should be changed in order to prevent further deaths. The Coroner sends this of to the relevant organisations / companies, and a copy to the Ministry of Justice. The relevant organisations / companies have to respond within a certain time.

Here is two examples I can think of:

Example 1 is one of my previous cases:
An elderly lady died in a nursing home. She died from after a fall she had and broke her leg. She fell because she was using a walking aid frame (called a Zimmer frame), and the wheels had come loose and she collapsed with the frame. The inquest found that no-one seems to be responsible for the maintenance and repair of those walking aids. The nursing home where she lives said that the walking aids are property of the hospital who issued them and it is their property, they thought the hospital should maintain and repair them. The hospital who gave her the walking aid said they don't know where people go to live with their frames, so they thought it is the people themselves who look after them. The Coroner has written to both hospital and nursing home to say that a suitable arrangements needs to be found.

Example 2 is one which I read in the press:

I can't remember the exact circumstances, but a child had died whilst climbing on a walking frame in a playground. He had gotten tangled in the frame with laces which had been on the coat he was wearing. The Coroner wrote to the manufacturer and health and safety board to change the design of coats. 

Peggy x