Inquests & Inquiries

Narrative Verdicts

Expert psychiatric evaluation for Narrative Verdicts in coronial proceedings—providing detailed evidence on the deceased’s mental state and the standard of forensic psychiatric care received. Urgent reports are available to meet court deadlines.

Section 12 Approved Psychiatrists
CPR Part 35 Compliant
Urgent Reports Available

Expert Type

  • Forensic Psychiatrist
  • Consultant Psychiatrist
  • Clinical Psychologist
  • Neuropsychologist

Applicable Law

  • Coroners and Justice Act 2009
  • Human Rights Act 1998
  • Article 2 ECHR
  • The Coroners (Inquests) Rules 2013
  • Mental Health Act 1983

When Needed

This assessment is required when a simple verdict cannot describe the circumstances of death, particularly in cases involving complex mental health histories or deaths in state detention.

What Is a Narrative Verdicts Assessment?

A Narrative Verdicts assessment involves a comprehensive psychiatric analysis used in the Coroner’s Court to explain the central circumstances surrounding a death. Unlike short-form conclusions, these provide a factual statement of the contributory factors related to the deceased’s mental health and clinical management.

The assessment evaluates whether clinical negligence or systemic failures in psychiatric provision played a role in the fatality. It is particularly crucial for Article 2 inquests, where the state’s duty to protect life is under scrutiny following a death in custody or psychiatric care.

  • Mental state at death — evaluation of the deceased’s psychological condition
  • Standard of care — assessment of whether clinical interventions met professional standards
  • Risk assessment — analysis of how suicide or self-harm risks were managed
  • Causal links — determining if omissions directly contributed to the outcome
  • Article 2 compliance — investigating potential breaches of the right to life
  • Prevention of future deaths — identifying systemic improvements to prevent recurrence

Our experts provide reports compliant with applicable Coronial procedural rules. Where parallel civil proceedings arise, CPR compliance can be provided separately. that assist the Coroner in reaching a balanced and evidence-based conclusion. These evaluations require a high degree of forensic expertise to interpret complex medical records and witness statements.

The resulting expert opinion offers clarity on whether psychiatric symptoms were appropriately treated or if the death was a foreseeable consequence of inadequate supervision.

Key Assessment Components

Our assessment evaluates the following areas:

Clinical Record Review

A meticulous analysis of psychiatric records and multidisciplinary team notes to establish the timeline of care.

Risk Analysis

Evaluating the historical and immediate risk management plans in place prior to the incident.

Care Pathway Evaluation

Assessing whether the care programme approach was implemented correctly and effectively.

Symptom Assessment

Reconstructing the deceased’s likely mental state based on collateral evidence and clinical documentation.

Legislative Compliance

Reviewing whether actions taken were consistent with the Mental Health Act and local trust policies.

Causal Nexus

Identifying whether specific clinical omissions or actions were significantly contributory to the death.

Conditions That May Affect This Assessment

A range of psychiatric and psychological conditions can affect this assessment. These include:

Severe Depressive Episodes
Schizophrenia and Psychosis
Personality Disorders (BPD/EUPD)
Bipolar Affective Disorder
Substance Misuse and Dual Diagnosis
Post-Traumatic Stress Disorder (PTSD)

The impact of these conditions can be highly variable over time, necessitating a retrospective analysis of fluctuating symptoms.

Assessment Process

  1. Instruction Received

    We receive formal instructions from solicitors or Coroners detailing the scope of the inquest and the specific questions to be addressed regarding the deceased’s mental health.

  2. Expert Matched

    We assign a Section 12 approved forensic psychiatrist with specific expertise in the relevant clinical area, such as prison healthcare or acute psychiatric wards.

  3. Assessment Conducted

    The expert performs a comprehensive documentary review, including medical records, police reports, and witness statements, to form a clinical opinion.

  4. Report Delivered

    A robust report prepared in accordance with Coronial procedural requirements is delivered, providing clear conclusions to assist the Coroner in reaching a narrative verdict.

Turnaround Times

Urgency Level Timescale
Standard Report 4-6 weeks from assessment
Priority Report 1-2 weeks
Urgent Report 1-4 days
We offer rapid turnaround for Narrative Verdicts reports to ensure all expert witness evidence is ready for pre-inquest reviews.

What’s Included in the Report

Detailed Psychiatric History
Review of Medical Records
Analysis of Risk Assessments
Review of Care Plans
Assessment of Mental State
Commentary on Clinical Care
Evaluation of Foreseeability
Response to Coroner’s Questions
Conclusions on Causation
CV of Expert Witness

All reports are quality-assured and our experts are available to provide oral testimony at the Inquest.

Frequently Asked Questions

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Need a Narrative Verdicts Report?

Contact us for a Narrative Verdicts assessment; we provide expert witness CVs and quotes within 60 minutes.