Inquests and the role of inferences in conclusions of suicide

The High Court decision in Toogood v HM Senior Coroner for Somerset provides important clarification on the evidential approach coroners may adopt when considering a conclusion of suicide with limited or no direct evidence of intent.

For healthcare providers and interested parties involved in inquests – the decision is a helpful reminder of what will – and won’t – succeed on a judicial review challenge.

Brief background

Mr Toogood, a retired farmer, died on or around 28 February 2024 at his home from a wound to the head inflicted by a shotgun. Shortly prior to his death, Mr Toogood had experienced a rapid decline in his mental state, observed by both his family and his GP. In February 2024, he reported anxiety, low mood and weight loss and had subsequently been prescribed antidepressant and anti-anxiety medication (although toxicology reports later suggested that he had not been taking it). Despite his deterioration in mood, Mr Toogood did not express any suicidal thoughts or leave a note and made routine purchases prior to his death such as buying a lottery ticket and a full tank of farm diesel.

The inquest took place on 8 December 2024. The Coroner inferred Mr Toogood’s suicidal intent from the factual and circumstantial evidence of the case, concluding that he ‘deliberately and intentionally ended his life by a self-inflicted shotgun wound to his head’.

The legal challenge

Following the inquest, an application for judicial review was made by Mr Toogood’s daughter (the Claimant), arguing that (a) the Coroner failed to ask appropriate questions of the medical expert, and (b) the process by which the Coroner concluded intent was flawed. In relation to the latter, the Claimant’s case principally rested on the fact that the Coroner could not rule out accidental discharge of the shotgun and that Mr Toogood’s mental deterioration before his death may have meant he lacked capacity to form the intent required in a conclusion of suicide.

The decision

The Judge dismissed the claim, clarifying that the Coroner was ‘not required to exclude every speculative or remote hypothesis advanced’ and could ‘draw reasonable inferences from circumstantial evidence’ when coming to a conclusion.

Although the Claimant had suggested Mr Toogood may have tripped in his hallway and accidentally triggered the shotgun, the Coroner relied on the pathologist’s evidence that this was unlikely and ‘stretched possibility’. The totality of the evidence was consistent with a finding of suicide, including Mr Toogood’s medical and psychiatric history, his experience with firearms and the inherent nature of the act itself.

In relation to Mr Toogood’s mental capacity, there was no direct evidence to suggest that he had been suffering from acute psychosis in the weeks leading up to his death and no medical professionals had raised any concerns about his capacity. The Coroner had therefore come to a conclusion based on ‘what probably occurred’ by considering the ‘inherent likelihood of the competing explanations’.

Comment  

Toogood clarifies that earlier authorities are no longer good law; a Coroner is no longer required to rule out every possible explanation before coming to a conclusion of suicide. This follows the approach taken by the Supreme Court in R (Maughan) v HM Senior Coroner for Oxfordshire, confirming that the civil standard (“on the balance of probabilities”) applies to inquest conclusions rather than the criminal standard (“beyond reasonable doubt”) and this may include drawing reasonable inferences where there is no direct evidence.

Importantly, however, Toogood clarifies that ‘suicide may not be presumed’; there must be some evidential basis for each element and not merely speculation where there are gaps in the evidence.

The Judge also dismissed the procedural challenge raised by the Claimant, confirming that the questions put to witnesses during an inquest were at the discretion of the Coroner based on what is necessary and proportionate, and need not be exhaustive. A failure to ask additional questions may only result in procedural irregularity if such questions are required for a fair enquiry.

The conclusion of suicide was therefore one reasonably open to the Coroner on the evidence before her.

Key takeaways

• Reasonable inferences can be drawn: direct evidence is not required for a finding of suicide. Circumstantial evidence can be enough, when taken as a whole, to prove the necessary intent on the balance of probabilities.
• Speculation is not sufficient: conclusions will turn on the probability of alternative explanations rather than their possibility.
• High bar for judicial review: a coroner’s decision can only be quashed on the basis that no reasonable coroner, properly directed, could have reached that conclusion on the evidence.

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