Although there are suggested forms of words for the verdict on the back of the inquisition form, there is no requirement that the verdict should be in any particular form. In certain circumstances some form of words other than those suggested on the inquisition form may be regarded as more appropriately reflecting how the deceased died. All that is necessary is that the verdict is expressed in concise and ordinary language. The only requirement is that the verdict must not appear to determine any question of criminal or civil liability on the part of a named person.

The following verdicts are those suggested on the back of the inquisition form:

  • Natural causes: This is appropriate where the evidence suggests that the deceased probably died as a result of some naturally occurring illness or disease process.
  • Died from industrial disease: Where the deceased died from an illness or disease, caused by chemicals or other agents to which they were exposed through their occupation, this verdict is appropriate. For example, this verdict has been returned where it has been proven that an individual’s death has resulted from asbestosis contracted through exposure to asbestos. In these circumstances the verdict may properly be recorded that the deceased died from industrial disease, rather than natural causes, which would otherwise be the appropriate verdict.
  • Died from dependence on drugs / non-dependent abuse of drugs: Where an individual’s death was a consequence of the use of drugs, this verdict is appropriate. It is usually returned in relation to illicit rather than prescription drugs. The verdicts distinguish between individuals who had a dependency upon the drugs they were abusing and those who did not.
  • Died from want of attention at birth: This verdict is appropriate where the deceased died as a result of a lack of attention at birth. It may be relevant to the death of a mother or an infant at birth.
  • Killed himself or herself / whilst the balance of his mind was disturbed: Before this verdict is returned the Coroner or jury should be satisfied beyond reasonable doubt that the deceased killed him or herself, and intended to do so. This is a high threshold, which is often satisfied only where there is positive evidence of the deceased's intention to kill him or herself, for example a suicide note (this is not usually read in open court). A finding that an individual intended to take his or her own life should only be inferred from the evidence in the clearest circumstances where there can be no other explanation: Re Davies (deceased). The Coroner should be satisfied that the deceased was capable of forming the intention to take his or her own life and was not, for example, acting under a delusion as part of a mental illness or whilst under the influence of alcohol or drugs. If the deceased was suffering from a psychiatric condition when he or she died, the Coroner may record that ‘the deceased killed him or herself whilst suffering from a psychiatric illness.’
  • Died as the result of an attempted/self induced abortion: This verdict is probably less relevant now than it was when medical termination of pregnancy was illegal and there was more recourse to self-termination of pregnancy.
  • Died as the result of an accident/misadventure: For statistical purposes the verdicts of accident and misadventure are treated as the same, although in reality the verdicts have slightly different meanings. An accident suggests something over which there is no human control (for example, a tree falling onto the road causing fatalities), whereas misadventure suggests a lawful human act, which takes an unexpected turn and leads to death. There is some authority suggesting that the term ‘misadventure’ is without purpose or effect, nonetheless it continues to be a verdict returned by Coroners in appropriate circumstances. For example, if the deceased died as a consequence of some medical intervention (perhaps a surgical accident causing a fatal injury or a death resulting from side effects of prescription drugs) a verdict of misadventure will reflect that the deceased died as a result of a lawful human act that had unintended consequences. To return a verdict of accident or misadventure the Coroner or jury must be satisfied on the balance of probabilities that this is how the death occurred.
  • Was killed lawfully: A person may be lawfully killed in only limited prescribed circumstances, for example, where the perpetrator inflicted a fatal injury whilst acting in self-defence.
  • Was killed unlawfully - murder, manslaughter, infanticide: A verdict of unlawful killing encompasses findings of murder, infanticide or manslaughter (voluntary or involuntary). To return a verdict of unlawful killing the Coroner or jury needs to be satisfied beyond reasonable doubt that this is how the deceased came to his death. A Coroner cannot find any person guilty of any of these offences. In some circumstances it may be obvious that a particular person was involved. In other cases, it will be impossible to infer from the verdict who was responsible for the death and it is not for the court to enquire into this. If however, the Coroner or jury returns a verdict of "unlawful killing," although there is no sanction as a result of the verdict in itself the expectation would be that the Director of Public Prosecution would institute proceedings.
  • Stillborn: A stillborn infant is an infant born after 24 weeks, who did not breathe or show any other sign of life. If the Coroner finds that the infant was stillborn he or she will indicate this on the inquisition form, but the remainder of the form will not be completed, as he or she cannot properly enquire into the death of a stillborn infant.
  • Open verdict: An open verdict is appropriate where there is insufficient evidence to record any of the other verdicts, i.e. the evidence fails to meet the required proof.
  • Neglect. In the appropriate circumstances the Coroner or jury may add to the verdict a finding that the deceased’s death was contributed to by neglect. Neglect has a different meaning from 'negligence.' The definition of the term 'neglect' in a Coroner’s court is set out in a case called R v. North Humberside Coroner ex parte Jamieson. It was held that: 'Neglect in this context means a gross failure to provide adequate nourishment or liquid, or provide or procure basic medical attention or shelter or warmth for someone in a dependent position (because of youth, age, illness or incarceration) who cannot provide it for himself’. The first element of neglect is the proof of a gross failure to provide care to a person in obvious need. The failure must be more than transitory or a 'mere' error of judgment. The following are examples of situations upheld by the court as capable of constituting 'gross' failures: a police surgeon's failure properly to search the deceased and thereby discover a bottle of pills, the failure to procure for the deceased effective medical treatment, and failure to monitor blood pressure of a mother following birth. The Coroner or jury must also be satisfied that the deceased was a dependent person. This requirement will usually be satisfied if the deceased was known to be at risk of self-harm, had been diagnosed as suffering from a mental illness, or was detained in prison or under the care of medical practitioners. The neglect must be directly connected with the deceased's death and must be at least a contributory cause.
  • Self neglect. This verdict is appropriate where a person dies due to his or her own self neglect, for example, an elderly person dying of hypothermia at home.
  • Narrative verdicts. The Coroner is not required to return a verdict in one of the set formats set out above. It is sufficient to produce a short, factual statement setting out the circumstances of the death if this more fairly and accurately reflects how the deceased came to his or her death. The House of Lords has recently endorsed the use of the narrative form verdict as a mechanism of recording by what means and in what circumstances the deceased met his or her death where an enhanced inquest is required by virtue of Article 2 of the ECHR: R v Her Majesty’s Coroner for the Western District of Somerset ex parte Middleton. In these situations the verdict may include information about where and when the death took place, the cause or causes of the death and, if relevant, any individual or systemic relevant to the circumstances of the death.

Prevention of similar fatalities

The Coroner has power (rule 43, Coroners Rules) to report to a person or authority, any action that he or she believes should be taken to prevent the recurrence of similar fatalities in the expectation that steps will be taken to prevent similar fatalities in the future.

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