A Coroner s perspective on a conclusion of suicide. Michael Singleton HM Senior Coroner Blackburn, Hyndburn & Ribble Valley

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1 A Coroner s perspective on a conclusion of suicide Michael Singleton HM Senior Coroner Blackburn, Hyndburn & Ribble Valley

2 Coronial Areas England and Wales is currently divided into 92 Coronial Areas of differing sizes. Each area has a Senior Coroner and a number of Assistant Coroners. Since July 2013 all newly appointed coroners are lawyers. All Coroners are independent. There is a Chief Coroner to provide guidance.

3 Coroners and Justice Act 2009 S1 A senior coroner who is made aware that the body of a deceased person is within that coroner s area must as soon as practicable conduct an investigation into the person s death if the coroner has reason to suspect that- (a) the deceased died a violent or unnatural death, (b) the cause of death is unknown, or (c) the deceased died while in custody or otherwise in state detention.

4 Matters to be ascertained S5 The purpose of an investigation is to ascertain- (a) who the deceased was; (b) how, when and where the deceased came by his or her death; (c) the particulars required by the 1953 Act to be registered concerning the death.

5 Record of Inquest Rule 34 Coroners (Inquest Rules) 2013 A coroner or in the case of an inquest heard with a jury, must make a determination and any findings using Form 2. The following is the record of the inquest 1. Name of deceased: 2. Medical cause of death: 3. How, when and where the deceased came by his death: 4. Conclusion of the coroner/jury as to the death (see notes (i) and (ii)): 5. Further particulars required by the Births and Deaths Registration Act 1953 to be registered concerning the death.

6 Note (i) (i) One of the following short-form conclusions may be adopted- I. accident or misadventure II. alcohol / drug related III. industrial disease IV. lawful / unlawful killing V. natural causes VI. open VII. road traffic collision VIII. stillbirth IX. suicide

7 Note (ii) As an alternative, or in addition to one of the short-form conclusions listed under Note (i), the coroner or where applicable the jury, may make a brief narrative conclusion.

8 Suicide Suicide is voluntarily doing an act for the purpose of destroying one s life while one is conscious of what one is doing. In order to arrive at a conclusion of suicide there must be evidence that the deceased intended the consequence of the act. In practical terms the conclusion can only be returned where it is shown that:- (a) the death occurred as a result of a deliberate act by the deceased; and (b) that in doing so (and at all material times) he intended that the consequence would be his own death.

9 Standard of Proof In the case of suicide (and unlawful killing) the standard of proof is the criminal standard of beyond a reasonable doubt. That standard of proof relates to both parts. In various criminal cases in the Crown Court and in various cases in the High Court judges have tried to explain beyond a reasonable doubt. So as to be sure. A reasonable doubt being one more than merely fanciful. all other possible explanations being totally ruled out. so as to be certain.

10 R(Barber) v City of London Coroner [1975] 3 All ER 538 Lord Widgery suicide must never be presumed. If a person dies a violent death, the possibility of suicide may be there for all to see, but it must not be presumed merely because it seems on the face of it to be a likely explanation. Suicide must be proved by evidence, and if it is not proved by evidence, it is the duty of the coroner not to find suicide, but to find an open verdict.

11 R (Lagos) v HM Coroner for City of London [2013] EWHC 423 Lang J I agree with the Claimant that the circumstances of her death, combined with the evidence of her mental state in the period leading up to her death, makes suicide the most probable explanation. But, in law, the coroner had to be sure that Mrs Lagos intended to commit suicide, and did in fact do so. All other possible explanations for the death had to be excluded.

12 Open Conclusion An open conclusion should be returned when there is insufficient evidence to the necessary standard of proof enabling a substantive conclusion to be recorded

13 Narrative conclusions R (Longfield Care Homes Ltd) v HM Coroner for Blackburn [2004] Mitting J In cases where the death results from more than one cause of different types, a narrative conclusion will often be required.

14 Problems for coroners in applying the standard of proof. University of Cambridge Institute of Criminology factors impacting interpretation of criminal standard of proof. Interpretation of suicide notes. Intention to end life v intention to determine circumstances of death. Preparation v execution. State of mind. Possibility of rescue. What do we mean by certain? Can intention be inferred from motive? Can intention be inferred from method used?

15 My Conclusions (1) Cases of suicide are under reported. (2) There is considerable disparity of approach amongst coroners. (3) Statistical analysis is unreliable.

16 Any Questions?