The question of whether a coroner’s verdict of suicide/unlawful killing may be decided on the civil burden of proof has been considered by the High Court of Justice Queen’s Bench Division in the judicial review of R (on the application of Thomas Maughan) –v- HM Senior Coroner for Oxfordshire [2018] EWHC 1955 (Admin).inquest


This claim arose from an inquest concerning the death of a prisoner who was found hanging in his prison cell in July 2016. Having heard the evidence over the course of the inquest in October 2017, the coroner accepted that there was insufficient evidence upon which the jury could be sure that the deceased intended to kill himself and hence did not leave them the option of a short-form conclusion of ‘suicide’.

Instead, the coroner invited the jury to record a narrative conclusion. However, the questions he left to the jury included:

  1. whether the deceased had deliberately placed a ligature around his neck and suspended himself
  2. whether he intended the outcome of doing so to be fatal

The coroner provided the jury with written instructions that the standard of proof in answering those questions was to be the balance of probabilities (i.e. whether it was more likely than not).The narrative statement from the jury subsequently included a finding that the deceased had deliberately tied the ligature around his neck and suspended himself from the bedframe, and that it is more likely than not that he intended to fatally hang himself.

The claim

The deceased’s family made the claim in judicial review on the basis that the jury’s conclusion amounted to a conclusion of suicide, reached on the balance of probabilities. The family argued that a conclusion of suicide, whether short-form or as part of a narrative statement, may only be returned on the criminal standard of proof - beyond all reasonable doubt.

The court concluded that inquests are held in the civil jurisdiction and, therefore, that the civil standard of proof should apply to all conclusions. Consequently the judicial review application failed.


The impact of this conclusion is potentially wide reaching. Whilst healthcare clients are unlikely to be concerned as to the standard of proof in respect of suicide conclusions, the obiter comments in paragraphs 45 to 48 of the judgment provide that conclusions of unlawful killing should also be decided on the balance of probabilities.

Organisations should be aware therefore that, where there are serious concerns relating to the care given, and that care (or lack thereof) is causative of the death, it is likely that, as well as conclusions with a neglect rider, coroners will also consider whether a conclusion of unlawful killing should be returned.

The claimant has been granted permission to appeal – so whilst this remains good law for the time-being, this is not yet the end of the road.