Keoghs Insight


Gemma Rush

Unlawful Killing: Maughan and Chief Coroner’s Law Sheet Number 1


The Supreme Court’s decision in R (on the application of Maughan) v Her Majesty’s Senior Coroner for Oxfordshire [2020] (Maughan) lowered the standard of proof for a conclusion of unlawful killing from the criminal standard of ‘beyond reasonable doubt’ to the civil standard of the ‘balance of probabilities’. 

Since then the Chief Coroner HHJ Teague QC has produced guidance for coroners. That has been updated with the latest Law Sheet Number 1 dated 1 September 2021.

A conclusion of unlawful killing may only be reached, following an inquest, when the coroner or jury is satisfied on the balance of probabilities that a death was caused by one of the following criminal offences:

  1. Murder;
  2. Manslaughter;
  3. Infanticide

Such a conclusion can be considered along with all other possible conclusions; now they must all be established on the balance of probabilities. However, due to their gravity, the guidance is that it remains sensible to consider unlawful killing before suicide (if applicable) and either or both of those short form conclusions before any other. Further, in summing up where unlawful killing is a potential conclusion, the coroner should direct the jury clearly as to what needs to be established (each element of the criminal offence or offences on which the conclusion might be founded) and what they have to find as facts to justify the conclusion. 

Whilst no conclusion of unlawful killing may name the person responsible, it may be obvious from the circumstances, evidence and summing-up who is regarded as responsible. The Chief Coroner’s view is that a finding of unlawful killing which is based on gross negligence manslaughter or corporate homicide will not breach s10(2) of the Coroners and Justice Act 2009 as it is not a conclusion which appears “to determine any question of criminal liability on the part of a named person, or civil liability”, merely because one ingredient is the breach of a duty of care as there will be no express determination that a civil wrong has been committed. 


Whilst an inquest is not a determination of criminal liability, it is a concern for affected individuals and companies. It is questionable whether the majority of the public appreciates a conclusion of unlawful killing would not result in an individual or company being criminally responsible. The knock-on effect to reputations and consequently the financial impact could be significant.

 Such a conclusion will also influence regulators and result in such inquests becoming more adversarial, with more separately represented interested persons and an increased use of witnesses refusing to answer questions that may lead to self-incrimination. Overall, it is likely the process will become more complex, increasing the time required by the court both at pre-inquest reviews and at the inquest.

 For further information please contact Gemma Rush