13 November 2020

In a judgment handed down today in the case of R (Maughan) v. HM Senior Coroner for Oxfordshire, the Supreme Court has decided that the standard of proof for all conclusions at an inquest, including unlawful killing and suicide, is the balance of probabilities. 

Until now, the standard of proof for unlawful killing has been the criminal standard – beyond reasonable doubt. Today’s judgment means that for all conclusions at an inquest, the standard is the same. The coroner or jury may record a conclusion (including unlawful killing) if they are satisfied that it is more likely than not that it occurred. 


James Maughan died by hanging in his prison cell at HMP Bullingdon on July 11, 2016. The coroner at the inquest into his death directed the jury to reach a narrative conclusion, applying the civil standard of proof, which is the balance of probabilities. They were asked to determine whether Mr Maughan deliberately placed a ligature around his neck and suspend himself, intending the outcome to be fatal.  Those are the questions to be answered in respect of a short-form suicide conclusion. However, the coroner held that the jury could not leave suicide as a short-form conclusion, because the standard of proof was criminal (beyond reasonable doubt), and they could not properly find it was satisfied. 

Mr Maughan’s brother brought a claim for judicial review to challenge the direction and jury’s conclusion. He argued that the standard of proof for a suicide conclusion is the criminal standard, whether it is expressed as a short-form or narrative conclusion. The Divisional Court decided in July 2018 to lower the standard of proof for suicide, so that it is the civil standard.  

INQUEST intervened in the Court of Appeal and Supreme Court. They argued that, if the standard of proof for suicide is the lower standard, then the standard for unlawful killing should also be the lower standard. 

The Supreme Court today confirmed the Divisional Court’s conclusion as to the standard for suicide. It also accepted INQUEST’s submission and decided that the standard of proof for unlawful killing is the lower civil standard. 

Deborah Coles, Director of INQUEST, said: “The new lower standard of proof for unlawful killing is an important and significant change to inquest law and should mark a step forward for state and corporate accountability.

More bereaved families can expect the gravity of the conduct of state agents to be recognised as unlawful killings which, when combined with narrative conclusions, will help ensure inquests hold state agents to account and better identify wrongdoing. We hope families will feel vindicated by conclusions that properly reflect the severity of ill treatment, state violence and neglect all too prevalent in deaths at the hands of state agents and in detention settings.

The lower standard of proof for suicide will make it all the more important that narrative conclusions include any failures connected to the death. Indeed the judgment recognises the importance of narrative findings at inquests, and that they have led to systemic learning and prevention, which is of vital importance to bereaved families.



For more information, contact INQUEST communications team on 020 7263 1111 or [email protected] 

INQUEST were represented by Adam Straw of Doughty Street Chambers, instructed by Helen Stone of Hickman & Rose Solicitors. Mr Maughan was represented by Karon Monaghan QC, of Matrix Chambers, and Jude Bunting, of Doughty Street Chambers, instructed by Najma Rasul of Matthew Gold Solicitors. 

James Maughan, 34, was found hanged in his cell on July 11, 2016. Oxford Coroner’s Court held a four day inquest in October 2017.

The Court of Appeal, on 9 April 2019, ruled coroner’s could apply the civil court standard and only had to be satisfied that it was “more probable than not” that a person had deliberately killed themselves. This was consistent with the decision reached by the Divisional Court on 26 July 2018.

The Supreme Court heard the case on 26 and 27 February 2020, before handing down the judgement today (13 November).