In R (on the application of Evandro Lagos) v HM Coroner for the City of London [2013] EWHC 423 (Admin), the Court considered and gave guidance on the standard of proof to be applied when returning a verdict of suicide as well as the rationale for applying that standard.

Mrs Lagos was found dead in July 2010. There was evidence that she had been mentally disturbed in the period preceding her death and had previously selfharmed. The Claimant, her husband, contended that the only conclusion the coroner could have reached in the circumstances was that his wife had committed suicide. Accordingly, he challenged the decision of the coroner, who sat without a jury, to record an open verdict on the grounds that this infringed Article 1 of the Universal Declaration of Human Rights. A verdict of suicide would, he argued, have acknowledged and respected the way in which she chose to end her life and thus accorded her the dignity to which she wasentitled under Article 1. Mr Lagos also challenged the findings of the coroner on a number of additional grounds including a refusal to disclose a police report, the change of an interpreter and the controlling of witness evidence at the inquest.

In considering the challenge to the return of an open verdict, Mrs Justice Lang emphasised that the conclusion of a coroner sitting alone as to the appropriate verdict involves an evaluation of the evidence and provided that he directs himself correctly as to the ingredients of the verdict, his decision may only be impugned if it is unreasonable in the Wednesbury sense: R v City of London Coroner, Ex Parte Barber [1975] 1 WLR 1310 at 1313 (Lord Widgery CJ). In the context of a verdict of suicide, the standard of proof to be applied is the criminal standard of proof (in contrast to that generally applicable which is the civil standard of the balance of probabilities). Thus, in order to return a verdict of suicide, the coroner or jury must be sure “beyond reasonable doubt”

  1. that the deceased intended his own death; and
  2. that he did an act with that intention which caused his death.

Mrs Justice Lang noted that the only other verdict to which this standard applies is that of unlawful killing and reiterated that a high standard is deliberately set in order to ensure that such serious findings are only made on the basis of absolutely clear and compelling evidence:R v West London Coroner, Ex Parte Gray [1988] 1 QB 467. Further, consistently with the high standard of proof, suicide must not be presumed simply because it seems a likely, or the most likely, explanation of events. Mrs Justice Lang set out in some detail the authorities in support of the principle that suicide cannot be presumed including the relatively recent decision in R (Jenkins) v HM Coroner for Bridgend and Glamorgan Valleys [2012] EWHC 3175 (Admin), in which the Divisional Court quashed the result of inquest proceedings in part because the coroner’s direction to the jury had paid insufficient regard to the important principle that suicidal intention and action cannot be presumed and must be proved to the strict standard of proof. She summarised the rationale behind these principles as follows:

“..the approach of the Courts to suicide verdicts reflects (a) the fact that a finding of suicide is a serious matter which can cause serious distress and stigma, and other adverse consequences; and (b) the complexities of human psychology which can cause people to harm themselves seriously or to put themselves in very dangerous positions without the clear intention to end their lives.”

On the facts, she held that there had been no misdirection as to the appropriate test and the argument that failure to return a suicide verdict amounted to a breach of Article 1 of the Universal Declaration of Human Rights failed – the open verdict was simply the consequence of applying the relevant legal tests.

As to the procedural challenges, namely, the refusal to disclose a police report, a change in the Claimant’s interpreter and the decisions of the coroner to restrict certain questioning of witness evidence, in dealing with these matters (and in rejecting the challenges in each case), the Judge emphasised the broad discretion that is conferred upon a coroner and the relatively high threshold for establishing that this discretion has been unlawfully exercised. Thus, for example, in relation to the coroner’s power to control witness evidence (as defined by section 11 of the Act), the provision involves a two-limb test of relevance and expediency, and a coroner’s selection of witnesses may only be challenged if unreasonable in the Wednesbury sense. Equally, Lang J held that it is an established principle that the scope of inquiry at an the production of the verdict, and that the Courts will only rarely interfere with decisions as to scope: R v Inner West London Coroner, Ex Parte Dallaglio [1994] 4 All ER 139. Whilst on the facts the Judge accepted that the coroner had intervened in the questioning of certain witnesses, this did not meet the threshold for a finding of procedural unfairness.

The issue of when it will be appropriate to leave it to the jury to return a verdict of suicide was raised in R (on the application of Sreedharan) v HM Coroner for the County of Greater Manchester and others [2013] EWCA Civ 181 (see above). The Appellant in that case contended that the coroner had erred in directing the jury that they were not entitled to return a verdict of suicide.Lady Justice Hallett indicated that she had initially been attracted by the force of the Appellant’s arguments as to the weight of the evidence justifying a verdict of suicide. In particular, the deceased had a history of self-harm and suicide attempts and had threatened to kill himself in the days before his death. However, the evidence was “far from all one way”:

“The question of whether or not a judge or coroner should leave an issue to a jury may sometimes be a difficult one to answer; not all cases are clear cut. It then becomes very much a matter for the judgement of the judge or coroner who has seen and heard the evidence tested to decide. An appellate court will rarely intervene. In my judgment, this is such a case. The Coroner having seen and heard the evidence concluded that a properly directed jury could not exclude the possibility that this was not a suicide. That was a reasonable approach to take and not one with which I would interfere. There was no error of law.”

Further, Lady Justice Hallett concluded that a failure to leave suicide could not be said to have undermined the integrity of the verdict which was returned. The Coroner left to the jury the possibility of accident and an open verdict. They were directed to start with consideration of unlawful killing and work their way down the list if necessary. Had they not been satisfied as to unlawful killing they had other options:

“The jury system in this country depends on our trusting a jury to follow directions. Thus, their verdict indicates they had no doubt that the prescription of a dangerous drug to a volatile and vulnerable patient was a material cause of Mr Donohue’s death and that whatever roles the emergency services, Mr Donohue, and his
mother played, they were not sufficiently potent to break the chain of causation.”