Supreme Court ruling on standard of proof in inquests: implications for work-related accidents

R (on the application of Maughan) v Her Majesty’s Senior Coroner for Oxfordshire [13.11.20]

On 13 November 2020, the Supreme Court handed down its judgment in this case concerning the standard of proof applicable for determining suicide and unlawful killing in inquest proceedings.

Dismissing the appeal with a majority of 3-2, the court reached a decision that has significantly altered the burden of proof required in order to reach the conclusion of suicide or unlawful killing at an inquest. In this article we consider the implications for cases involving fatal work-related accidents.

The decision

This case concerned an inquest into the death of Mr James Maughan, who was found hanged in his prison cell on 11 July 2016.

The Senior Coroner for Oxfordshire applied the Chief Coroner’s Guidance on Conclusions which states that in order to reach a conclusion of suicide, the standard of proof to be applied is the higher criminal standard of proof “beyond reasonable doubt”. The coroner directed that, taking into consideration the evidence heard, the jury could not safely be left a short form conclusion of suicide but could find a narrative conclusion acknowledging the facts of Mr Maughan’s death (including that the deceased intended the fatal outcome) to the lower, civil standard of proof “on the balance of probabilities”.

The decision of the Senior Coroner for Oxfordshire was appealed to the Divisional Court, and then to the Court of Appeal before reaching the Supreme Court. In its ruling, the Supreme Court confirmed that the lower civil standard of proof should be applied to suicide conclusions. The court also found that the civil standard should be applied to the determination of a conclusion of unlawful killing. All conclusions at inquests will therefore now be reached on the civil standard of proof.


The majority of the Supreme Court’s judgment focusses on the burden of proof for the conclusion of suicide, as that was the issue that was directly applicable to the death of Mr Maughan and the basis of the preceding appeals. Whilst that will of course be very significant in many inquests, particularly those involving similar facts, the change in the burden of proof for unlawful killing conclusions will be of particular concern to those involved in fatal work-related incidents.

A conclusion of unlawful killing is limited to circumstances where the elements of the criminal offences of murder or manslaughter (including corporate manslaughter) are present. These elements were previously required to be present “beyond reasonable doubt” before the potential conclusion of unlawful killing could be left to a jury, but now it can be left to a jury even where those elements could be said to be present only on the “balance of probabilities”. The consequence being that historically inquests involving fatal work-related deaths rarely saw conclusions of unlawful killing being left to the jury. We now expect to see this conclusion much more frequently.

With the lower standard of proof now applicable to a finding of unlawful killing, if an inquest returns such a conclusion, there is now greater risk of re-investigation for homicide offences after the inquest has concluded.

Whilst individuals cannot be named in an inquest conclusion, they may be implicated by default in a finding of unlawful killing and this could well have a significant impact on their professional reputation, regardless of whether the police go on to investigate them individually as potential suspects.

In effect, a finding of a criminal offence (i.e. an unlawful killing conclusion) can now be proved to a lower standard at an inquest, without the ability of those implicated to make representations on the evidence or ‘defend’ themselves, had the same offence been tried in a criminal court.

Prior to this case, coroners were required to adjourn the inquest and refer the case to the Director of Public Prosecutions (DPP) where the death of the deceased was likely to be due to a homicide and a person or organisation could be charged in relation to the offence. But this rarely happened. The Supreme Court’s recent judgment is likely to make this a more common occurrence. In addition, even if the coroner does not refer the case to the DPP, bereaved families can invoke their right to have the decision to not previously prosecute for a homicide offence reviewed by the Crown Prosecution Service. These factors could cause further delays to what can be a lengthy and difficult legal process to navigate.

Careful consideration will need to be given to fatal accident cases where an unlawful killing conclusion is now a realistic possibility and attentive inquest planning and preparation will be even more important.

Read others items in Health, Safety and Environment Brief - December 2020

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