How does the coroner or jury reach a conclusion?

In reaching any conclusion, the Coroner has to be sure ‘on the balance of probabilities’ (or more likely than not) that this is how someone died.

A conclusion of suicide and unlawful killing used to be held by the criminal standard (beyond reasonable doubt) but this was changed to be ‘on the balance of probabilities’ in May 2019, following the case of Maughan.

N.B. The Maughan decision does not retroactively apply to inquest conclusions.