The inquest into the death of Jean Charles de Menezes illustrates dramatically a serious flaw in the framework governing coroners’ investigations — the inclusion in inquest findings of short-form verdicts such as accidental death, misadventure, natural causes, lawful killing and unlawful killing.

Until the coroner’s directions to the jury on the verdicts open to them, the De Menezes inquest seems to have been a model of inquisitorial co-operation. But when the coroner ruled out unlawful killing and instructed the jury to choose between lawful killing and an open verdict, Mr de Menezes’ family mounted a demonstration in court and their legal team left the proceedings.

When conducting the independent review of the coroner and death certification services set up in 2001 by David Blunkett, then Home Secretary, it became clear that the verdicts generate more heat than light. It is not just that they are unnecessary: they also stand in the way of giving the family and the wider public a properly informed and balanced account of how a death happened, and what, if anything, might have prevented it.

Many inquests have to resolve complex and contentious issues about the causes and circumstances of deaths. In cases where there is dispute about the suitability of treatment of someone who dies in hospital, a sensible inquest finding would often be in terms of probability, not certainty — for example that a different treatment might, or probably would, or probably would not, have avoided the death. But this cannot be conveyed in the type of two-word phrase allowed to juries and coroners in these headline verdicts. Similarly, cases involving deaths at the hands of the police often turn on difficult judgments of the degree of danger presented by the person who is killed and the options open to the police for managing the risk to themselves and the public.

There is nothing in the phrases lawful killing or unlawful killing that conveys or helps to elucidate such judgments: the very steep tests the higher courts have erected to legitimate an unlawful killing verdict — the beyond reasonable doubt evidentiary standard, and the gross negligence test for a manslaughter finding — leave the more normal human failings of incompetence and misjudgment without any natural home in the range of available verdicts.

The prohibition in Rule 42 of the Coroners’ Rules on framing any verdict “in such a way as to appear to determine any question of (a) criminal liability on the part of a named person, or (b) civil liability” means that except in cases where a death is caused by an unknown and unidentified assailant, the unlawful killing verdict is rarely if ever legitimately available.

There is of course the option of an open verdict, but generally speaking that is simply a signal that the jury or coroner could not settle the case within the short-form verdicts they were permitted to consider.

In our report we said of this aspect as it affects the experience of bereaved families in complex and contested cases: “If the coroner, mindful of the care shown in the civil and criminal justice systems to protect all parties from casual incrimination or imputations of liability, steers the proceedings away from unlawful killing, the family is likely to feel that the system has offered them a glimpse of a meaningful outcome but then made it virtually unattainable. This is to design conflict and disappointment into the system.”

The law does not require these short-form verdicts and does allow narrative findings that can do much better justice to the complex circumstances of death found in many cases, as indeed other parts of the De Menezes inquest findings show. The Coroners’ Rules also provide for the provision of a report by the coroner on systems improvements to prevent other deaths in similar circumstances — a report on these lines is still to come on the De Menezes case.

We concluded that the coroner’s inquest needed radical improvement and reform if it were to regain public confidence. Some of the reforms we advocated have been applied in individual cases — appointing members of the senior judiciary to preside over exceptionally complex inquests, and supporting them with counsel to the inquest, for example.

Next year the Government is introducing legislation to modernise the long-neglected coroner system and reform the still more neglected and unsatisfactory death certification procedures. This will provide a perfect opportunity to get rid of short-form verdicts, or at the least to give the inquest system a strong push away from them to fuller and more reasoned analytical judgments of why unnatural deaths have occurred and how they can be prevented.

The author chaired the Fundamental Review of Coroners and Death Certification in England, Wales and Northern Ireland (2001-03)

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