Maughan, R (On the Application Of) v Senior Coroner for Oxfordshire

The standard of proof for a conclusion of suicide at an inquest is the balance of probabilities, whether the conclusion is recorded in short form or narratively. An inquest is an inquisitorial fact-finding investigation, not a criminal proceeding, and no principled basis exists for applying the criminal standard merely because suicide is a serious or potentially stigmatising finding. Suicide must not be presumed: the evidence must be sufficiently cogent to justify the conclusion and must permit the coroner or jury to exclude competing explanations. A narrative conclusion which records suicidal intent proved only on the balance of probabilities is not thereby converted into an unlawful conclusion.

James Maughan died by hanging while in custody at HMP Bullingdon. At the inquest, the coroner directed the jury to apply the balance of probabilities when determining whether he deliberately suspended himself and intended the outcome to be fatal. The jury returned a narrative conclusion making those findings.

The claimant sought judicial review, arguing that a conclusion of suicide, whether short-form or narrative, required proof beyond reasonable doubt. The central issue was whether the criminal standard applied to suicide conclusions at inquests.

1. The claim was dismissed. The coroner’s directions were lawful and the jury’s narrative conclusion was valid.
2. A narrative conclusion stating that, on the balance of probabilities, the deceased deliberately performed an act causing death with the intention that it be fatal is substantively a conclusion of suicide. It cannot be rescued by describing the recorded standard of proof as insufficient. If the criminal standard applied, the conclusion would be unlawful; the proper answer is instead to determine which standard the law requires.
3. The general rule is that the standard of proof depends on the nature of the proceedings, not the nature of the fact alleged. Civil proceedings use the balance of probabilities even where criminal conduct is alleged. Seriousness and consequences may affect the assessment of inherent probabilities, but do not create a variable or heightened standard.
4. Modern coroner’s proceedings are inquisitorial fact-finding investigations. They have no parties, indictment or prosecution, and conclusions do not determine criminal or civil liability. The historical criminal functions of coroners have been abolished. There is therefore no principled analogy with criminal proceedings requiring proof beyond reasonable doubt.
5. The authorities that suicide must not be presumed establish a requirement for sufficient evidence and prohibit speculation or filling gaps in the evidence. They do not establish a criminal standard. R v West London Coroner, ex parte Gray was wrong on this point, and its observations concerning suicide were in any event dicta. The court was not bound by that Divisional Court decision and declined to follow it. R (Evandro Lagos) v HM Coroner for the City of London, which followed ex parte Gray, was also wrongly decided.
6. Note (iii) to Form 2 under the Coroners (Inquests) Rules 2013 stated the perceived law but did not itself legislate the standard of proof. The claim was accordingly dismissed.

First-instance judicial review decision. No prior judgment in the same proceedings is stated.