Inquests - A move away from narrative conclusions?

The recent Chief Coroner’s guidance, “Conclusions: short-form and narrative”, was issued with the stated purpose of assisting coroners in the use of short-form and narrative conclusions, with a view to achieving greater consistency. Interestingly, contrary to the current trend in health and safety inquests, the guidance tells coroners that, wherever possible, short-form conclusions should be delivered. 


The Coroners and Justice Act 2009, the Coroners (Inquests) Rules 2013 and case law provides for two forms of conclusion:

  1. A short-form conclusion; and
  2. A narrative conclusion. 

Where necessary, both a short-form and a narrative can be combined to provide an appropriate conclusion.

The guidance

The recent guidance issued by the Chief Coroner states that wherever possible, coroners should conclude with a short-form conclusion.

The guidance states that the short-form conclusion should be one from the list of short-form conclusions in the Coroners (Inquests) Rules 2013. The list includes:

  • Accident or misadventure;
  • Alcohol/drug related;
  • Industrial disease;
  • Lawful/unlawful killing;
  • Natural causes;
  • Open;
  • Road traffic collision;
  • Still birth; and
  • Suicide.

Although the list is not exhaustive, the guidance points coroners in the direction of the list, advising that “straying from the list will usually be unwise”. Open conclusions are discouraged, to be used only as a “last resort”.

As is often the case in inquests involving health & safety issues, the guidance provides that as an alternative to a short-form conclusion the coroner (or the jury if so directed by the coroner) may record a brief narrative conclusion. The guidance reminds coroners that narrative conclusions should be a brief, neutral, factual statement and should not express any judgment or opinion. The Chief Coroner acknowledges that there has been a tendency for narrative conclusions to become lengthy and far-reaching and the clear guidance to coroners is that long narratives should not be given because they are neither clear nor easy to assess for statistical purposes.

To allay any confusion, the guidance breaks down the constituent parts of the findings to be made by the coroner or the jury during the inquest process. The three elements are:

  1. The findings of fact;
  2. Answering ‘how the deceased died’; and
  3. The conclusion.

The Chief Coroner makes the point that if these three stages are properly followed, there will often be no need for a narrative conclusion.

To illustrate how the three stages should be approached, the Chief Coroner makes reference to previous findings of accidental death which have included a brief description of the circumstances of the death. The examples given include: ‘the deceased was killed when his car was run down by an express train on a level crossing’ and ‘the deceased was drowned when his sailing dinghy capsized in heavy seas’. The Chief Coroner explains that these should not be narrative conclusions, but the information should be used to answer ‘how the deceased died’, leaving the short-form conclusion of ‘accident’ to stand alone.

Health & safety inquests

The current trend for inquests into workplace fatalities appears to be for juries to return narrative conclusions. As explained above, the Chief Coroner has issued guidance that wherever possible, coroners should conclude with a short-form conclusion. The reason given is that short-form conclusions have the advantage of being simple and accessible for bereaved families and the public, as well as being clear for statistical purposes. Even in complex cases, and many workplace health & safety cases would be considered complex, the Chief Coroner is of the opinion that short-form conclusions will often be sufficient.

Inquests into health & safety incidents are often complicated and can last for many days or even weeks. They generally involve a number of witnesses and can take place a significant time after the death occurred. By their very nature, inquests are emotional and often traumatic for family, friends, witnesses and colleagues. With this in mind, it is not difficult to understand why in many health & safety cases, the jury are not minded to return a short-form verdict, opting instead for a narrative conclusion.

After months of waiting, anticipation and preparation, and days or weeks of evidence, it feels almost insufficient for the conclusion to be as simple as ‘accident’. So, whilst short-form verdicts might make statistical analysis easier, we will have to wait and see how coroners implement the guidance in health & safety inquests and whether they more frequently direct juries towards short-form conclusions.

This information is intended as a general discussion surrounding the topics covered and is for guidance purposes only. It does not constitute legal advice and should not be regarded as a substitute for taking legal advice. DWF is not responsible for any activity undertaken based on this information.

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Claire Notley


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