What do different Coroner’s Conclusions mean?
After investigating the circumstances of a death, the Coroner will reach a conclusion on what caused the death, and why. The options they can reach are limited to an Official list of Conclusions. You can find out more about the Inquest process in our dedicated inquest guide, but what do the different conclusions mean, and when might they be used?
Accident or misadventure
Whilst Accident and Misadventure are treated the same for statistical purposes they historically have slightly different meanings. Misadventure is where someone doing something lawful unintentionally kills another. The difference can be explained as accident reflecting death following an event over which there is no human control where as misadventure is an intended act but with unintended consequence. In a medical context misadventure could reflect intended treatment with an unintended consequence.
Alcohol / drug related
An alcohol or drug related death covers both a death from the poisoning effect of being an addict and an accidental death resulting from abuse of alcohol or drugs.
More easy to understand, a conclusion of death by reason of Industrial Disease is used when the Coroner is satisfied that the death resulted from a disease caused by work.
Lawful/ Unlawful killing
Lawful and unlawful killing will rarely arise in a medical context. Lawful killing is a deliberate act but justifiable such as self-defence. Unlawful killing is closely dies in with criminal proceedings which will take place before any inquest. Unlawful killing is the correct conclusion in cases of murder, manslaughter and infanticide.
This conclusion reflects the normal disease process and will be appropriate where someone dies as a result of disease naturally acquired. A Natural Causes conclusion will not apply where there the disease was caused by work (Industrial Disease). In a medical context a person who is suffering from a potentially fatal disease and where medical intervention fails to prevent the death will die from natural causes (as separate from possible misadventure). Natural causes does not absolve a doctor of fault just as misadventure does not imply fault. See more about Natural Causes here.
An open conclusion will be given if there is insufficient evidence to record any other suggested conclusion or where there is other evidence but the required standard of proof is not reached. It is a conclusion of last resort.
Road Traffic Collision
This is a relatively new conclusion and applies in any circumstances where someone dies as a result of an incident on the road and involves a vehicle.
Currently an inquest may be opened to ascertain whether a child was born alive or not. If the conclusion of the evidence is that the child was stillborn this will be the correct conclusion and no further investigation need be carried out. This is an area of law which is currently under review.
See more about stillbirth here.
This conclusion means self-murder. Taking your own life. Suicide must never be presumed and must be based upon some evidence that the deceased intended to take their own life.
In place of the short form conclusions listed above the Coroner can give a narrative conclusion. This is a brief explanation of the facts explaining how the deceased came by their death. This can include a reference to neglect.
This does not equate to Negligence. Neglect is limited in a medical context to cases where there has been a gross failure to provide basic medical attention to someone obviously in need of it, and where that gross failure has played a part in the death. See a more detailed piece on this a narrative including neglect here.