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Divisional Court rules on evidential standard for Coroners in suicide cases

In an unexpected judgment, the Divisional Court fundamentally changed the landscape of the law relating to conclusions of suicide in Coroner’s inquests.

The decision in R (Maughan) v HM Senior Coroner for Oxfordshire[1] overturned the established principle that the criminal standard of proof had to be reached for a conclusion of suicide to be found.

Facts of the case

Mr Maughan was an inmate at HMP Bullingdon, who it was agreed, took his own life by use of a ligature to the neck. The question to be determined by the Coroner was whether Mr Maughan intended to do so.

At the time of the inquest the established evidential threshold for such a finding was ‘beyond reasonable doubt’ – the criminal standard of proof. The jury had to be sure that Mr Maughan took his own life and intended to do so.

Whilst summing up to the jury, the Coroner assessed that there was – applying the evidential threshold – insufficient evidence for them to reach a ‘short-form’ conclusion of suicide. The Coroner directed the jury to consider, in the alternative, a narrative conclusion and prepared a questionnaire requiring the jury to consider questions relevant to suicide.

Critically, the evidential threshold the jury had to meet to consider these questions was the civil standard – the balance of probabilities test.

The jury returned a narrative conclusion that they were satisfied that Mr Maughan deliberately tied a ligature around his neck and probably intended to kill himself.

The appeal

The deceased’s brother, aggrieved at how the court had arrived at the conclusion of suicide, seemingly circumventing the established standard of proof, appealed the decision.

The Divisional Court agreed that, in principle, a Coroner must not seek to side-step the evidential standard required for a short-form conclusion by utilising the procedures and lower evidential standard of a narrative conclusion to achieve the same result.

Nevertheless, the Court rejected Mr Maughan’s appeal, in so doing the court embarked on an examination of the reasonableness of the established standard of proof in cases of suicide.

The court observed that in the civil jurisdiction, the test to establish suicide remains the balance of probabilities standard.[2] Provoking the question, why should there be a different standard in coronial proceedings?

Different evidentiary standards

The Court identified that the inquest conclusions of both unlawful death and suicide were classified differently to other short-form conclusions. Historically, this could be attributed to the fact that prior to the Criminal Law Act 1977, a jury verdict could result in a named party being committed to trial in the criminal courts. Given that this process no longer exists and the fact that suicide ceased to be a criminal offence following the Suicide Act of 1961, the Court questioned what jeopardy required the protection of a higher evidential threshold:

‘Where the function of an inquest is to determine the relevant facts concerning the death as accurately and completely as possible without determining even any question of civil liability, we can see no justification in principle for weighting the fact-finding exercise against any particular conclusion and requiring proof to any higher standard than the balance of probabilities. That is so even if the facts found disclose the commission of a criminal offence.’

The Court recognised the challenges in assessing the mental state of a person who had taken their own life, but concluded that this did not justify two conflicting evidential standards:

‘The fact that the human mind is often hard to fathom cannot be a reason for imposing a higher than normal standard of proof.’

Finally, the Court also assessed the factor of the cultural and religious stigma attached to suicide as a possible reason for justifying the higher evidential standard, ultimately rejecting the argument, stating:

‘Is it not for the law in this area to adopt one conception of human dignity in preference to another.’

The Court cited the authority of R (Lagos) v HM Coroner for the City of London in which the claimant had argued volubly for a conclusion of suicide as it was the only conclusion that would adequately express his late wife’s agency in making a choice to end her own life.

Unlawful killing

This bold decision provokes an interesting question: Does the evidential standard for unlawful killing survive this judgment? Perhaps not.

What prejudice is caused to an individual where a conclusion of unlawful killing is made by a coroner? That individual is not named, the effect of the Criminal Law Act 1977 means that criminal proceedings do not automatically flow from an inquest conclusion and evidence of a Coroner’s conclusion is pursuant to the rule in Hollington v Hewthorn[4] inadmissible.

What difference is there between a Coroner’s conclusion and any other in civil proceedings where a Court determines that someone has committed a serious criminal offence? Here the standard of proof would remain, the civil standard.[5]

It will be interesting to see how this difficult issue develops. It does seem likely that in the light of the decision in Maughan we will see a significant increase in the number of cases where conclusions of suicide will be found.

How we can help

We are recognised leaders in the field of healthcare law and practice, with extensive knowledge in mortality governance, inquest investigations, regulatory proceedings and health and safety prosecutions. If you require advice on any issue related to the content of this article please contact:

Graeme Irvine
T. 020 7227 7238

[1] R (Maughan) v HM Senior Coroner for Oxfordshire [2018] EWHC 1955 (Admin) (Leggatt LJ, Nicol J)
[2] Braganza v BP Shipping Ltd [2015] UKSC 17; [2015] 1 WLR 1661, paras 33-35
[3] R (Lagos) v HM Coroner for the City of London [2013] EWHC 423 (Admin)
[4] More recently expressed in Hoyle v Rogers [2014] EWCA Civ 257
[5] Hornal v Neuberger Products Ltd [1957] 1 QB 247


This briefing is for guidance purposes only. RadcliffesLeBrasseur LLP accepts no responsibility or liability whatsoever for any action taken or not taken in relation to this note and recommends that appropriate legal advice be taken having regard to a client's own particular circumstances.

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