A long-awaited decision of the Court of Appeal has clarified that a lower standard of proof should apply than previously thought before an Inquest can return a conclusion of suicide.

The ruling makes it likely that more Inquests will reach a formal conclusion of suicide and provide greater consistency in the reporting and recording of suicides. Where suicides arise in a care setting, there will undoubtedly be greater scrutiny of the actions of the care provider and whether effective steps could have been taken to intervene.


For nearly four decades the law appeared settled that to reach a conclusion of suicide the coroner or jury would have to be convinced to the criminal standard, so that they were sure the deceased acted deliberately and with an intention to kill themselves.

As a result, even where the evidence made it more likely than not that the deceased committed suicide, the Court could not return a verdict of suicide unless the higher standard was reached. As a result, where some doubt about the deceased's intentions remained, the only conclusion available was often an open verdict – reaching no positive conclusion about the nature of the death.

The 2016 Health Select Committee Inquiry into suicide prevention raised a concern that there was inconsistency in the recording and reporting of suicide by coroners. Clear and accurate statistics are clearly important in understanding key trends and allowing effective action to reduce suicide rates.


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For many years the law appeared to be settled about the extent of the evidence needed to support any conclusion. For all conclusions except suicide and unlawful killing the coroner or jury only needed to be convinced on the balance of probabilities, such that the outcome was more likely than not. To conclude suicide or unlawful killing, the coroner or jury would need to be convinced to the higher criminal standard. In such cases, the evidence would need to convince them so that they were sure the deceased committed suicide or was unlawfully killed.


In July 2016, James Maughan was found hanging in his prison cell at HMP Bullingdon. A ligature had been tied to the bed frame and attached to his neck. There was evidence that in the past, he had mental health and other problems and attempts at suicide and self-harm.

The key issues in the inquest were whether the hanging was self-inflicted and deliberate, whether James Maughan intended to kill himself and whether his death was caused or contributed to by a failure to protect his life on the part of the prison authorities.

The coroner concluded that the evidence was insufficient and too weak to allow the jury to return a confident verdict of suicide. The coroner did, however, allow the jury to return a narrative conclusion, in which they found on the balance of probabilities his actions were deliberate and that he intended to hang himself fatally.

The outcome was challenged by the family, who did not believe that James had intended to kill himself. They argued that the requirement for an outcome of suicide to be established to the criminal standard should also apply to a narrative conclusion that sets out all of the key ingredients of suicide.

In a recent ruling, (R (on the Application of Maughan) v HM Senior Coroner for Oxfordshire [2019] EWCQ Civ 809) the Court of Appeal confirmed that a conclusion of suicide would only need to be established to lower civil standard of proof. All of the earlier authorities reviewed by the court assumed that the higher standard would apply, but none created an explicit precedent to that effect. However, the Court of Appeal concluded that the higher standard of proof would continue to apply to the outcome of unlawful killing.


The lower standard of proof is likely to lead to an increase in the number of Inquests formally concluding that the deceased committed suicide. That should result in greater consistency in the recording and reporting of suicides, hopefully allowing for more effective preventative action in the future.

The increased likelihood of a formal finding of suicide may place greater scrutiny upon those responsible for providing care to those at risk with the potential for negative publicity; could more effective action have been taken?

It is vital that early advice is taken in such cases to ensure that care providers are ready to explain the care provided and that where ongoing risks have been identified, effective action has been taken.

Further information

For more information about any of the subjects raised in this briefing, please contact Tim Coolican