Summary
The balance of probabilities is the standard of proof for every conclusion at a coroner’s inquest. It applies equally to short-form and narrative conclusions, including suicide and unlawful killing.
Note (iii) to Form 2 in the Coroners (Inquests) Rules 2013 did not codify the former common-law requirement of proof beyond reasonable doubt. It stated the law as then understood and did not prevent judicial development of the common law. A suicide conclusion nevertheless requires affirmative proof that the deceased took their own life and intended to die. It cannot be inferred merely because other possible causes have been excluded.
Factual background
R v Her Majesty’s Senior Coroner for Oxfordshire arose from the inquest into James Maughan’s death in prison. The coroner concluded that the jury could not safely return a short-form conclusion of suicide beyond reasonable doubt. The jury was nevertheless permitted to find, on the balance of probabilities, that Mr Maughan had intended fatally to hang himself.
The Divisional Court held in [2018] EWHC 1955 (Admin) that the civil standard governed suicide conclusions. The Court of Appeal affirmed that decision in [2019] EWCA Civ 809, while retaining the criminal standard for unlawful killing because it was bound by existing authority.
The central issue was whether suicide required proof beyond reasonable doubt and whether Note (iii) to Form 2 in the Coroners (Inquests) Rules 2013 fixed that standard by statute.
Held
By a majority of three to two, the appeal was dismissed.
Lady Arden, with whom Lord Wilson agreed, held that section 45 of the Coroners and Justice Act 2009 was broad enough to authorise procedural rules prescribing a standard of proof. A standard of proof forms part of the process of determining facts and falls within the power to regulate practice, procedure and evidence.
Note (iii) to Form 2 formed part of an enactment, but its meaning depended on its statutory and consultative context. That context showed that the note recorded the common law as it was understood when the Coroners (Inquests) Rules 2013 were made. It did not codify the rule or prevent the courts from correcting and developing the common law. Lord Carnwath agreed that the note was naturally read as guidance about the existing law rather than as a prescription of the applicable standard.
The ordinary civil standard therefore applied to suicide conclusions. Inquests are inquisitorial investigations concerned with establishing facts, rather than criminal proceedings which determine guilt. Applying different standards to narrative findings and a short-form conclusion within the same inquest would be internally inconsistent. The balance of probabilities still requires affirmative proof that the deceased took their own life and intended to die; suicide cannot be inferred simply by eliminating other causes.
The civil standard also applied to unlawful killing. A uniform standard accords with the fact-finding purpose of an inquest and avoids inconsistency between narrative and short-form conclusions. Section 10(2) of the Coroners and Justice Act 2009 prevents a determination from appearing to decide the criminal liability of a named person. The possibility of adjourning an inquest where criminal proceedings may be brought provides further protection. The standard of proof for all short-form conclusions is therefore the balance of probabilities.
Lord Kerr, with whom Lord Reed agreed, dissented. He considered Note (iii) to be an operative statutory rule requiring proof beyond reasonable doubt for short-form conclusions of suicide and unlawful killing. In his view, inquests are sui generis, and the gravity and consequences of those conclusions justified the different standard.
The court’s approach to earlier authorities
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Appellate history
- United Kingdom Supreme Court: In R v Her Majesty’s Senior Coroner for Oxfordshire [2020] UKSC 46 , the court dismissed the appeal by a majority of three to two. It affirmed the civil standard for suicide and held that the same standard applied to unlawful killing.
- Court of Appeal: In [2019] EWCA Civ 809 ; [2019] QB 1218 , the court affirmed that the balance of probabilities applied to short-form and narrative suicide conclusions. It retained the criminal standard for unlawful killing because it was bound by existing Court of Appeal authority.
- Divisional Court: In [2018] EWHC 1955 (Admin) ; [2019] 1 All ER 561, the court held that the balance of probabilities applied to a conclusion of suicide, whether expressed in short form or through a narrative.
Appeal route
- Appealed from[2019] EWCA Civ 809This appealappeal dismissed by a majority of three to two
- This judgment [2020] UKSC 46 United Kingdom Supreme Court
Key cases cited
The 30 most senior of 31 authorities cited.
- Braganza v BP Shipping Limited and another [2015] UKSC 17
- In re CD (Original Respondent and Cross-appellant) (Northern Ireland) [2008] UKHL 33
- In re B (Children) (FC) [2008] UKHL 35
- Regina v. Her Majesty's Coroner for the Western District of Somerset (Respondent) and another (Appellant) ex parte Middleton (FC) (Respondent) [2004] UKHL 10
- Clingham (formerly C (a minor) v Royal Borough of Kensington and Chelsea (on Appeal from a Divisional Court of the Queen's Bench Division); Regina v Crown Court at Manchester Ex p McCann (FC) and Others (FC) [2002] UKHL 39
- In re H (Minors) (Sexual Abuse: Standard of Proof) [1996] AC 563
- Duggan, R (on the application of) v HM Assistant Deputy Coroner for the Northern District of Greater London & Ors [2017] EWCA Civ 142
- Sreedharan, R (on the application of) v HM Coroner for the County of Greater Manchester & Ors [2013] EWCA Civ 181
- LG, R (on the application of) v The Independent Appeal Panel for Tom Hood School & Anor [2010] EWCA Civ 142
- Birmingham City Council v Shafi & Anor [2008] EWCA Civ 1186
- Gough v Chief Constable of the Derbyshire Constabulary (Lilley v Director of Public Prosecutions, R (Miller) v Leeds Magistrates’ Court) [2002] EWCA Civ 351
- Kirkham v Chief Constable of the Greater Manchester Police [1990] 2 QB 283
- Lagos, R (on the application of) v HM Coroner for the City Of London [2013] EWHC 423 (Admin)
- Jenkins v HM Coroner for Bridgend and Glamorgan Valleys [2012] EWHC 3175 (Admin)
- B v Chief Constable of Avon and Somerset Constabulary [2001] 1 WLR 340
- R v Coroner for North Humberside and Scunthorpe, Ex parte Jamieson (Jamieson, Ex parte) [1995] QB 1
- In re Sutherland (deceased) [1994] 2 NZLR 242
- Anderson v Blashki [1993] 2 VR 89
- R v HM Coroner for Solihull, Ex p Nutt [1993] COD 449
- In re Beckon (1992) 93 DLR 4th 161
- R v HM Coroner for Newbury, Ex p John (1991) 156 JP 456
- R v Wolverhampton Coroner, Ex parte McCurbin (McCurbin, Ex parte) [1990] 1 WLR 719
- McKerr v Armagh Coroner [1990] 1 WLR 649
- Hunt v RM Douglas (Roofing) Ltd [1990] 1 AC 398
- R v Inner South London Coroner, Ex parte Kendall (Ex p Kendall) [1988] 1 WLR 1186
- R v West London Coroner, Ex parte Gray (Duncan, Ex parte, Gray, Ex parte, R v West London Coroner, Ex parte Duncan) [1988] QB 467
- R v Coroner for North Northumberland, Ex p Armstrong (1987) 151 JP 773
- R v HM Coroner for Dyfed, Ex p Evans (unreported), Divisional Court, 24 May 1984
- In re Davis, decd [1968] 1 QB 72
- Hornal v Newberger Products Ltd [1957] 1 QB 247
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Cases citing this case
14 later cases · 7 positive · 3 neutral · 3 caution · 1 negative
Most senior citing decisions:
- Emerald Josephine Toogood v HM Senior Coroner for the Area of Somerset [2026] EWHC 634 (Admin) followed
- Douglas and Carol Shipsey v HM Senior Coroner for Worcestershire [2025] EWHC 605 (Admin) mentioned
- Eileen Henshaw, R (on the application of) v HM Assistant Coroner for Derby and Derbyshire [2025] EWHC 357 (Admin) applied
- Sean Glaister & Anor, R (on the application of) v HM Assistant Coroner for North Wales (East and Central) [2025] EWHC 167 (Admin)
- Hillary Smith, R (on the application of) v Director of Public Prosecutions [2024] EWHC 2032 (Admin)
- Natasha Miranda Bryan, R (on the application of) v His Majesty’s Assistant Coroner for Buckinghamshire [2024] EWHC 26 (Admin)
- Ben Leeson & Anor v Donald McPherson [2023] EWHC 2502 (Ch)
- Police Officer B50, R (on the application of) v His Majesty's Assistant Coroner for the East Riding of Yorkshire and Kingston upon Hull [2023] EWHC 81 (Admin)
- Ghaleb Makki, R (on the application of) v HM Senior Coroner for South Manchester [2023] EWHC 80 (Admin)
- William Leeson, R (on the application of) v His Majesty’s Area Coroner for Manchester South [2023] EWHC 62 (Admin)
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