Saturday, 11 May 2019

Coroners ~ Suicide ~ Standard of Proof

At around 5.20 in the morning of 11 July 2016 James Maughan was found hanging in his prison cell at HMP Bullingdon. A ligature had been tied to the bedframe and attached to his neck. He was pronounced dead shortly thereafter. There was evidence that in the past he had mental health and other problems and that there had been previous attempts at suicide and self-harm.

In such circumstances, an inquest was required to be held and was held. The inquest took place between 9 and 12 October 2017 before the Senior Coroner for Oxfordshire and a jury.

The principal issues raised
at the inquest were whether the hanging was self-inflicted and deliberate; whether, if it was, the deceased intended to kill himself; and whether his death was caused or contributed to by failure to protect his life on the part of the prison authorities.

At the conclusion of the evidence the Coroner heard submissions from various interested persons and, having done so, decided that the evidence was insufficient to enable a jury, properly instructed, to conclude to the criminal standard of proof that the deceased intended to take his own life.  The Coroner decided that the jury's conclusion on the circumstances in which the deceased had died should be elicited by way of narrative conclusion from them. To that end he asked the jury to answer 5 questions.  In accompanying written instructions, the Coroner made clear that, in reaching their conclusions on the questions posed, the jury were to apply a standard of proof by reference to the balance of probabilities.  For the purposes of the narrative conclusion the questions and instructions throughout were framed by reference to the civil standard of proof.

The deceased's brother challenged the determination, contained in the narrative conclusion of the jury, that the deceased had intended to kill himself.   The complaint in essence was that the jury were incorrectly instructed by the Coroner: they should only have been permitted to reach such a conclusion by applying the criminal standard of proof.   However, the High Court delivered a reserved judgment concluding - "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."  This judgment is at [2018] EWHC 1955 (Admin) - Leggatt LJ and Nicol J.

The Court of Appeal (Civil Division) has agreed with the High Court - R (Maughan) v HM Senior Coroner for Oxfordshire [2019] EWCA Civ 809 - Underhill, Davis and Nicola Davies LJJ.

The standard of proof to be applied throughout at inquests, and including both short-form conclusions and narrative conclusions, is the civil standard of proof.

Although the case was directly concerned only with a case of suicide, the court thought that it would be wrong, in the circumstances, not to comment (albeit on an obiter basis) on the standard of proof applicable to cases at inquests where the issue of unlawful killing arose.  The court held that in such cases, Coroners should continue to instruct juries by reference to the criminal standard of proof in the way that they currently do.

It remains to be seen whether this matter goes on to the Supreme Court.


A conclusion that the deceased had committed suicide was, understandably, very distressing for the deceased's family.  The High Court heard evidence to the effect that the Maughan family held strong Catholic beliefs.  A statement of Deacon David Palmer dated 14 June 2018 indicated that the teaching of the Catholic Church is that suicide is contrary to love for the living God and is considered a grave sin. 

Those holding such a viewpoint prefer that a conclusion that the deceased intended to kill himself must not be reached other than by applying the criminal standard (i.e. sure or beyond reasonable doubt).

Nevertheless, some organisations have campaigned for a change in the law.  For example, Papyrus (Prevention of Young Suicide) - stated:

"Suicide was decriminalised in 1961 – yet the Criminal Standard of Proof, ‘beyond reasonable doubt’, remained a requirement in reaching a conclusion of suicide. PAPYRUS believes that this has perpetuated the stigma around suicide and obscured the true scale of suicide in England and Wales. That is why we have campaigned for a change in the law so that the Civil Standard of Proof, the ‘balance of probability’, is required instead, pressing for change to the Coroners and Justice Act 2009.

In 2017 the House of Commons Health Committee recommended that the Civil Standard of Proof be used in reaching a conclusion of suicide .....  a breakthrough came in July 2018 when the High Court ruled that the civil standard of proof (on the balance of probabilities) should now be used by coroners in reaching a conclusion of suicide at inquest rather than the criminal standard (beyond all reasonable doubt)."

House of Commons - Health Committee - Suicide Prevention Inquiry 2017 and see paras 30 and 31 of this report

30. Currently a conclusion of suicide must meet the ‘criminal’ standard of proof, that is, that the coroner or jury must be certain, beyond reasonable doubt, that the person took their own life and intended to do so. We heard from witnesses that the standard of proof for conclusions of death by suicide should be changed to meet the civil standard, that is, on the balance of probabilities.  As Professor Appleby told us, “its equivalence with criminal proof reflects the history of suicide. [ … ] There is a principle here, which is that that standard of proof is a reflection of a system that is full of prejudice and stigma, which we ought to dismantle.”  As the Chief Coroner told us in written evidence, “what standard of proof applies in relation to conclusions in the coroner’s courts is a matter ultimately for Parliament”

31.Our evidence suggests the need for a more rapid provisional notification of suicide at the time when a suspected death by suicide occurs. We recommend that the Government take action to improve consistency between coroners and to make routine the use of provisional notifications of suicide. Furthermore, we recommend that the standard of proof for conclusions of death by suicide should be changed to the balance of probabilities rather than beyond reasonable doubt.

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