Limitations of neglect at inquest

• Covers case law on neglect in an inquest.
• Traces the evolution and scope of neglect.

A finding of neglect at the conclusion of an inquest can have profound implications, not least reputationally to those implicated in causing a death. It invariably carries with it an element of censure quite different from all of the short form conclusions that an inquest may return, except for unlawful killing. Neglect contributes to adversarial tensions in what is essentially an inquisitorial process. This is despite the fact that a finding of neglect is not a freestanding conclusion at all, but a ‘rider’ or adjunct to one.

That it is frequently misreported and misunderstood is perhaps not surprising considering its curious nature, as a judgmental finding in an essentially non-judgmental process. Although its application is relatively limited, the concept of neglect has played a significant role in pushing the boundaries of coronial law and in making the investigation of unnatural deaths by coroners