What Do Different Coroner's Conclusions Mean?

• Published date: 11 March 2021
• Subject Matter: Litigation, Mediation & Arbitration, Food, Drugs, Healthcare, Life Sciences, Court Procedure, Professional Negligence, Food and Drugs Law
• Law Firm: Enable Law
• Author: Ms Jackie Linehan

After investigating the circumstances of a death, the Coroner will reach a conclusion on what caused the death, and why. The options they can reach are limited to an Official list of Conclusions. You can find out more about the Inquest process in our dedicated inquest guide, but what do the different conclusions mean, and when might they be used?

Accident or misadventure

Whilst Accident and Misadventure are treated the same for statistical purposes they historically have slightly different meanings. Misadventure is where someone doing something lawful unintentionally kills another. The difference can be explained as accident reflecting death following an event over which there is no human control where as misadventure is an intended act but with unintended consequence. In a medical context misadventure could reflect intended treatment with an unintended consequence.

Alcohol / drug related

An alcohol or drug related death covers both a death from the poisoning effect of being an addict and an accidental death resulting from abuse of alcohol or drugs.

Industrial disease

More easy to understand, a conclusion of death by reason of Industrial Disease is used when the Coroner is satisfied that the death resulted from a disease caused by work.

Lawful/ Unlawful killing

Lawful and unlawful killing will rarely arise in a medical context. Lawful killing is a deliberate act but justifiable such as self-defence. Unlawful killing is closely dies in with criminal proceedings which will take place before any inquest. Unlawful killing is the correct conclusion in cases of murder, manslaughter and infanticide.

Natural Causes

This conclusion reflects the normal disease process and will be appropriate where someone dies as a result of disease naturally acquired. A Natural Causes conclusion will not apply where there the disease was caused by work (Industrial Disease). In a medical context a person who is suffering from a potentially fatal disease and where medical intervention fails to prevent the death will die from natural causes (as separate from possible misadventure). Natural causes does not absolve a doctor of fault just as misadventure does not imply fault. See...