A new standard of proof for a conclusion of suicide

  • 30 July 2018 30 July 2018
  • UK & Europe

  • Healthcare

A decision from the High Court late last week has changed the standard of proof in Coroners' inquests from the criminal down to the civil standard. R (Maughan) v Her Majesty's Senior Coroner for Oxfordshire [2018[ EWHC 1955 (Admin). 

A new standard of proof for a conclusion of suicide


On 11 July 2016 Mr Maughan was found hanging in his prison cell at HMP Bullingdon. An inquest was held in October 2017 by the defendant, HM Senior Coroner for Oxfordshire, with a jury. After the close of the evidence, the coroner decided that there was insufficient evidence for the jury to be ‘sure’ (the criminal standard) that Mr Maughan had intended to take his own life and therefore could not return the short form conclusion of ‘suicide’. The coroner invited the jury to record a narrative conclusion which answered five questions, including whether or not James Maughan had deliberately placed a ligature around his neck and whether he intended the outcome to be fatal (as opposed to being rescued).  The jury were also asked if they felt there were any errors or omissions on 10-11 July 2016 in the provision of care which caused or contributed to his death. The coroner directed the jury to consider whether the deceased was unable to form a specific intent to take his own life through mental illness. Finally, they were directed to make their findings on the balance of probabilities (the civil standard).

The jury decided on the balance of probabilities, that Mr Maughan had intended to fatally hang himself and that neither opening an ACCT, nor increased vigilance, would have prevented his death, given his intention to end his life.

The claim

In this judicial review, the claimant contended that the jury's conclusion was unlawful, as it amounted to a conclusion of suicide but reached on the balance of probabilities. The claimant submitted that decades (if not centuries) of case law had established that the criminal standard was necessary for this conclusion (and that of unlawful killing).


The High Court (which did not include the Chief Coroner) decided that the narrative conclusion did amount to a finding of suicide, even though that term was not used.

However, in examining the case law, the Court determined that although previous judgments have emphasised that suicide should never be presumed, none were authority for asserting that suicide must be proved to the criminal standard of proof. As a result, in the interests of simplicity, consistency and uniformity, a single standard of proof should be applied in all civil cases, just as a single (though higher) standard of proof is applied in all criminal cases.

The judgment also considered the distinction and differences between an inquest and criminal proceedings and concluded that overall: "Given the nature and function of a modern inquest, it seems to us that there is today no relationship or analogy between coroner’s proceedings and criminal proceedings which can in principle justify applying in coroner’s proceedings the criminal standard of proof” and “..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.”

Although the court sympathised with the distress felt by the claimant (at the conclusion of suicide), it was indicated that this cannot be a reason to avoid a conclusion. 

In dismissing the claim, LJ Leggatt concluded “we are unable to accept the claimant’s contention that a conclusion of suicide at an inquest requires proof to the criminal standard.  We are satisfied that the authorities relied on to support that contention either on analysis do not support it or do not correctly state the law.  We consider the true position to be that the standard of proof required for a conclusion of suicide, whether recorded in short-form or as a narrative statement, is the balance of probabilities, bearing in mind that such a conclusion should only be reached if there is sufficient evidence to justify it.”


We await confirmation as to whether this decision will be appealed. In recent years, there has been a growing unease with the criminal standard of proof being required for suicide, when a person taking their own life is no longer a crime. However some believe that suicide is a pejorative conclusion made about the deceased, that should only be found when all other possibilities have been ruled out. Regardless of those different views, the decision that Coroners have been applying the ‘wrong’ standard for decades would have a significant impact on all of the previously decided cases. 


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