Introduction
When writing police procedural fiction, I have to make sure that the many aspects of UK law and procedure regarding sudden or unexplained deaths are accurate. While working on my latest novel, I realised I’d used some outdated terminology, specifically the term “open verdict.” So, I went back over the subject to make sure I was up to date with current law. This post is my attempt to share that “refresher” research.
When someone dies suddenly or in unclear circumstances, the legal system has a duty to investigate what happened. In England, Wales, and Scotland, this is handled differently—but the aim is the same: to determine the cause of death and whether anything could have been done to prevent it.
This post explains what coroners (in England and Wales) and Procurators Fiscal (in Scotland) do, how inquests and fatal accident inquiries work, and what it means when the outcome is simply that no conclusion can safely be drawn.
What Does a Coroner Do?
In England and Wales (Scotland is covered shortly), a coroner is responsible for investigating deaths that are sudden, unexplained, violent, or occur in state custody. The purpose of an inquest is not to assign blame, but to establish the facts: who died, and how, when, and where they died. After hearing the evidence, the coroner (or sometimes a jury) will reach a conclusion about the cause and circumstances of the death.
What Happens to the Body?
When a death is referred to the coroner, they may authorise a post-mortem examination (the US term is autopsy) to help establish the cause. During this time, the body is legally under the control of the coroner and cannot be released for burial or cremation until the investigation is complete. This ensures that no evidence is lost or destroyed before all necessary enquiries have been made.
In Scotland, the Procurator Fiscal has similar powers. If the cause of death is unclear or suspicious, they may instruct a post-mortem. As in England and Wales, the deceased’s body remains under legal control until the Fiscal concludes their investigation and authorises release.
The Possible Conclusions for Sudden or Unexplained Deaths
An inquest in England and Wales can result in several “short-form” conclusions. These include:
- Natural causes
- Accidental death
- Suicide
- Unlawful killing
- Misadventure
- Drug or alcohol-related death
- Industrial disease
- Stillbirth
- Open conclusion
If a short-form conclusion isn’t sufficient to describe what happened, the coroner may instead use a narrative conclusion, which sets out the facts in more detail without assigning blame.
Open Conclusions
In England and Wales, if a coroner or jury can’t determine whether someone died by suicide, was murdered, or died accidentally—and there isn’t enough evidence to be sure either way—they may return what’s called an open conclusion.
This used to be known as an open verdict, but the terminology changed in July 2013 when the Coroners and Justice Act 2009 came into effect. The meaning, however, remains the same: the death is officially recorded as unexplained because the available evidence doesn’t clearly support any specific conclusion.
For example, if someone is found dead and it’s unclear whether it was suicide or foul play, and the available evidence doesn’t meet the legal threshold for either, an open conclusion may be recorded. It’s essentially the coroner’s (or jury’s) way of saying: “We don’t know, and we can’t say for sure.”
When Do the Police Take Over?
Police are often involved from the outset when a death is sudden or unexplained. Initially, they assist in securing the scene, identifying the deceased, and gathering preliminary information for the coroner. However, if there is any suspicion of foul play, evidence of violence, or circumstances suggesting unlawful killing, the police take over and open a criminal investigation.
In such cases, the coroner’s inquest may be adjourned until the police investigation—and any criminal trial—has concluded. If charges are brought, the findings of the inquest must not interfere with or pre-judge the outcome of the criminal process.
Once the trial is over, the coroner may resume the inquest to formally record the conclusion, especially if there are broader questions about how the death occurred or whether future deaths could be prevented.
When Is a Jury Required at an Inquest?
Most inquests are heard by a coroner sitting alone, but in some circumstances, the law requires a jury to be summoned. This includes cases where:
- The death occurred in state custody or detention (e.g. in prison or police custody),
- The death resulted from an act or omission of a police officer,
- The death was caused by a notifiable accident, poisoning, or disease, or
- The coroner believes a jury is necessary in the interests of justice.
In these cases, the jury listens to the evidence and helps reach a conclusion, though the coroner still directs them on the legal framework they must apply.
Who Can Become a Coroner?
In England and Wales, a coroner must be either:
- A qualified doctor, or
- A qualified lawyer (barrister or solicitor) with at least five years of experience.
Most coroners today are lawyers, although some have dual medical and legal qualifications. Coroners are appointed by local authorities, but they act independently and are not subject to direction from councils, the police, or the government when investigating deaths. Many also serve as Assistant Coroners or Area Coroners before being promoted to Senior Coroner for their jurisdiction.
Their role is not to establish guilt or liability, but to determine who died, and how, when, and where—and to ensure that deaths which are sudden, violent, or unexplained are properly investigated.
What About Scotland?
In Scotland, the system is different. There are no coroners. Instead, unexpected or suspicious deaths are investigated by the Procurator Fiscal—a public official who acts under the authority of the Lord Advocate.
If a death requires closer examination, the Procurator Fiscal may arrange a Fatal Accident Inquiry (FAI). Unlike inquests in England and Wales, FAIs do not deliver legal verdicts like “suicide” or “unlawful killing.” Their role is to establish the facts—where, when, and how someone died—and to make recommendations to prevent future deaths.
If the cause or intent behind a death remains unclear, the conclusion might be recorded as “undetermined intent”, but Scotland does not use the term “open conclusion.”
Who Is the Procurator Fiscal?
The Procurator Fiscal is a legally qualified official who works for the Crown Office and Procurator Fiscal Service (COPFS)—Scotland’s public prosecution and investigation service. They are solicitors or advocates trained in criminal and public law.
Unlike coroners, Procurators Fiscal handle a broader range of legal duties, including the prosecution of crimes and the investigation of deaths. All sudden, suspicious, accidental, or unexplained deaths must be reported to them. They then decide whether further investigation is needed and whether to instruct a post-mortem or pursue a Fatal Accident Inquiry.
They act in the public interest, and while they work closely with the police and medical professionals, they remain independent in their decision-making.
Why We Don’t Say “Commit Suicide” Anymore
Lastly, a note on language. The phrase “commit suicide” is falling out of use because the word “commit” carries strong associations with crime or sin—like “commit murder” or “commit a crime.” Until 1961, suicide was indeed a criminal offence in England and Wales, which is why the phrase took root.
Today, we understand that suicide is not a crime—it is a mental health crisis, often the result of deep psychological pain. Using more compassionate language helps to reduce stigma and encourages people to seek help.
That’s why many people now say “died by suicide” or “took their own life.” It’s a small change in how we speak, but one that can make a meaningful difference to those affected by suicide, or grieving a loved one.
Conclusion
Whether it’s a coroner in England and Wales or a Procurator Fiscal in Scotland, the aim of these investigations is to establish the facts for sudden or unexplained deaths, support bereaved families, and, where possible, learn lessons to prevent future deaths. While not every case brings definitive answers, the processes ensure that nothing is overlooked—and that transparency and public accountability are upheld.