Who's At Fault

It is not the Coroner’s role to establish who was at ‘fault’. Instead it is the Coroner’s role simply to establish what happened and to give his verdict accordingly. The Coroner can give a ‘short form’ verdict or a ‘narrative’ verdict.

Possible ‘short form’ verdicts are:

  • neglect
  • unlawful killing
  • suicide
  • attempted/self-induced abortion
  • accident/misadventure
  • natural causes
  • industrial disease
  • want of attention at birth
  • drugs dependency
  • open verdict
  • lawful killing

After hearing the evidence, the coroner will give the jury a summary of the evidence and will tell them what verdicts are available in the light of that evidence. The jury will then deliver its verdict. Sometimes the Coroner will give a verdict himself.

A coroner may choose to give a ‘narrative’ verdict in which he will provide a clear and concise statement of events. This will be phrased neutrally but often provides more information than simply giving one of the ‘short-form verdicts’. When there is a Jury the coroner may invite them to answer factual questions. If the inquest shows that something could be done to prevent other deaths, the coroner may report this to the relevant organisation that has the power to take action. This is referred to as a “Rule 43 Report”.