It is common for a Coroner to give a ‘Narrative conclusion’ in Article 2 inquests as this gives them the opportunity to give a more descriptive conclusion and highlight factual findings, particularly if there is evidence of serious failings.
Such conclusions can often include references to inadequate and unsuitable processes, actions and failings, highlighting areas of concern and for future improvement. Such conclusions can often be supportive of potential civil claims on behalf of our clients.