Independent report

Recommendations by Tim Godwin and Adrian Fulford to the Lord Chancellor and the Secretary of State for the Home Department

Published 23 October 2025

1. Executive Summary

It is frequently suggested that the result of the decisions in Maughan and W80 has been to assist in the important objective of reassuring the public that when police officers use unreasonable force in the discharge of their duties, a conclusion of unlawful killing at a Coroner’s Inquest or a finding of misconduct or gross misconduct in disciplinary proceedings will lead to greater police accountability and improvements in training and learning. Although we readily understand this widely-held perception, we consider it is based on a fundamental misunderstanding of the processes and procedures relating to inquests and misconduct hearings. For the reasons set out below, it is our view that there are impressive mechanisms for achieving accountability, enabling lessons to be learnt and identifying relevant training irrespective of the changes or clarification brought about by the decisions in Maughan and W80. Instead, there are indications that the adverse impact on police morale, recruitment and retention following these two decisions has been significant, troubling and enduring. Perhaps most significantly, we have seen the figures for the required and actual number of Counter Terrorist Specialist Firearms Officers (CTSFOs) and Armed Response Vehicle (ARV) officers within the Metropolitan Police and there is a significant gap. There is, at the least, a potential problem with recruitment and retention in this critical area of policing within certain areas of England and Wales. We recognise this is the result of a complex picture of which the decisions in Maughan and W80 are only a part, albeit in all likelihood a significant part given the decisions have gained something of a totemic status as providing a disincentive for applying for, or remaining in, these particular roles.

It is for these reasons that we suggest there is a compelling basis for concluding that the changes/clarification brought about by W80 and Maughan should be addressed utilising the mechanisms we have outlined. We fully recognise that there will need to be different levels of consultation and that if these steps, or either of them, are taken, they will require careful public explanation.

2. Introduction

1. Following the acquittal, on 21 October 2024, at the Central Criminal Court of Sergeant Martyn Blake on the charge of the murder of Chris Kaba, we were appointed by the Home Secretary and the Lord Chancellor (on 12 November 2024) to lead a “Rapid Review” of the different legal thresholds for reaching decisions concerning police officers in criminal, misconduct and inquest proceedings. The Home Secretary had explained on Wednesday 23 October 2024, in a statement to the House of Commons, that currently there is complexity, confusion and delay in the accountability systems when police officers use force or when they are involved in driving incidents. A key concern underpinning the need for a Review had been described by the National Police Chiefs’ Council (“NPCC”) on 17 October 2023 (in a document entitled “Submissions from the National Police Chiefs’ Council”(see following paragraph)), as follows: “the existing legislation underpinning use of force, including defences, provides insufficient protections for police officers operating in the line of duty, particularly in respect of firearms officers”.^{[footnote 1]} In the absence of a compelling case for immediate action, it is envisaged there will be further consultation on these issues, with a view to final recommendations being delivered later in 2025.

2. An earlier Police Accountability Review (“PAR”) had been launched on 24 September 2023. It was, in part, a reaction to two recent judicial decisions (considered in detail hereafter) which, as it has been suggested, created unfairness for some police officers who are subject to criminal, misconduct and inquest proceedings when they used force, lethal or otherwise. The PAR received evidence from the police, interested civil society organisations and others as to the different thresholds that are applied in these three separate types of proceedings when they concern police conduct. The previous Government, however, did not complete this exercise prior to the General Election on 4 July 2024 and, due to the risk of prejudice to Sergeant Blake’s trial, no further announcement was made until his trial had concluded.

3. As part of the wider review which the Home Secretary announced on 23 October 2024, we have been asked to assess whether there is a case for change in relation to two matters:

a) The legal test for use of force in misconduct cases, and whether it should be raised to the criminal test

4. This question principally arises following the Supreme Court decision in the case of R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents) [2023] UKSC 24 (“W80”) which determined that in disciplinary proceedings concerning the use of force by a police officer in self-defence, the civil law test is applicable, namely if the officer acted out of an honest but  mistaken belief that they or others were in immediate danger, they can rely on that belief only if the mistake was objectively a reasonable one. As a result, an officer who has used force can rely on the “reasonable belief” defence, and the objective test of “reasonable use of force” is to be assessed against the background of the facts as subjectively understood by the officer. However, if the officer made a mistake of fact, this can only be relied on if the mistake was a reasonable one for the officer to have made. This civil law test is to be contrasted with the criminal law test which enables the officer to rely on an honest belief regardless of whether or not that belief was mistaken, or, if mistaken, regardless of whether the mistake was a reasonable one for the officer to have made.

5. We have been asked to consider whether in our view there should be a return to the earlier position as regards the approach to be taken to honest belief in misconduct proceedings (namely, the criminal law test), taking into account the broad legal and policy implications of this step, along with the appropriate mechanism for implementing the change if it is to be made.

b) The threshold for determining a short-form conclusion of unlawful killing in coronial inquests

6. This question arises following the Supreme Court decision in R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent) [2020] UKSC 46 (“Maughan”), in which the court determined, albeit principally addressing the issue of suicide, that the civil standard of proof should be applied at a coroner’s inquest to the question of whether the deceased had been unlawfully killed, regardless of whether the finding was expressed by way of a short-form or narrative conclusion (see the following paragraph). We have been tasked with assessing the case for a return to the criminal standard for the short-form conclusion of unlawful killing. Again, in so doing, we have been asked to take into account the broad legal and policy implications of this step, along with the appropriate mechanism for implementing the change if it is to be made.

7. We should provide a short explanation of these two routes (i.e. the short-form and narrative conclusions). Section 10 of the Coroners and Justice Act 2009 (the “2009 Act”) requires the coroner (or the jury if there is one) to make a “determination” of the matters to be ascertained by the investigation and to make “findings” for registration purposes. The matters to be ascertained by the investigation into a person’s death are i) who the deceased was and ii) how, when and where the deceased came by his or her death (section 5). The section 10 “determination” and “findings” must be recorded on the Record of Inquest. In Box 3 of the Record of Inquest there will be entered a distillation from the findings of fact as to “how” the deceased came by his or her death. Normally, the answer to “how” will be a brief one sentence summary taken from the findings of fact. “How” usually means “by what means” and not “in what broad circumstances”, and what is required is a description of the mechanism of death, e.g. “from trauma consistent with an un-witnessed fall downstairs”. In Box 4 there will be recorded the conclusions which flow from and are consistent with the entry in Box 3. There are two alternatives as to how this can be completed in Box 4: i) a short-form conclusion (e.g. accident, misadventure, lawful killing, unlawful killing, suicide, open conclusion) and ii) a narrative conclusion. It is permissible, when appropriate, to combine the two types of conclusion. Narrative conclusions may be used in both Article 2 cases (viz. when the State has potentially failed to protect an individual’s right to life as enshrined in the European Convention on Human Rights) and non-Article 2 cases. For the former, it will be necessary, when appropriate, to satisfy the procedural requirements of Article 2, including, for example, reaching a “judgmental conclusion” on the events leading up to the death and the core facts directly relating to the circumstances of death. In all circumstances it is necessary to avoid attributing criminal liability to a named person or civil liability.

8. When a narrative conclusion includes the answers to “how, when and where”, the mechanism of death (viz. the “how”) is recorded in Box 3 with the wider narrative conclusion being provided in Box 4.

3. The Context of the Review in Detail

3.1 Misconduct Proceedings

9. The W80 case concerned the fatal shooting by police officer W80 of Jermaine Baker. The history to the case and the outcome of the final appeal in the Supreme Court are said to have highlighted the difficulties with the differing tests which, as set out above, currently apply across criminal, misconduct and coronial proceedings. Whilst the Crown Prosecution Service (“CPS”) were required to apply the subjective criminal law test to whether to charge W80 (resulting in no criminal charges), the Independent Office for Police Conduct (“IOPC”), applying the objective civil law test, directed the Metropolitan Police to refer the officer to misconduct proceedings. W80 challenged this direction by way of judicial review, and whilst he prevailed in the High Court, the IOPC won the resulting appeals in the Court of Appeal and the Supreme Court. Lord Lloyd-Jones JSC (with whom the other JJSC agreed) attached particular importance to the omission of the word “knowingly” in the 2008 and the later Police (Conduct) Regulations. The relevant wording changed from “Officers must never knowingly use more force than is reasonable, nor should they abuse their authority” (our emphasis) in the Police (Conduct) Regulations 1999 and 2004 to “Police officers only use force to the extent that it is necessary, proportionate and reasonable in all the circumstances”. Lord Lloyd-Jones’s presumption that this omission had been intentional was one of the significant foundation stones of the judgment. This is an issue which we discuss in detail below.

10. It is to be noted that a public inquiry on 5 July 2022 determined that Jermaine Baker had been lawfully killed, applying the subjective criminal law test for self-defence. The Chairman (H.H. Clement Goldstone KC) concluded that on the basis of the information known to the firearms officers, W80 was entitled to believe that the occupants of the car were in possession of at least one firearm. It was likely that Jermaine Baker moved his hand towards the bag he had on him “in a way that meant W80 honestly believed he was not complying with the instruction to place his hands on the dashboard”.^{[footnote 2]} The Chairman concluded that W80 could not be criticised for acting in self-defence although he had not seen any part of a weapon being taken from Jermaine Baker’s bag. Although “W80 may have been tragically wrong in his belief”, it would be wrong to determine “that it was not honestly held”.^{[footnote 3]} Accordingly, the Chairman found that W80 had lawfully shot and killed Jermaine Baker.

11. Notwithstanding that favourable finding vis-a-vis W80, in August 2023 comprehensive and positive amendments were made by the College of Policing to the Authorised Professional Practice on Armed Policing (“APP-AP”) resulting from the recommendations of the Chairman in this case, as well as from operational learning and from an armed policing inspection by His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services. These amendments were necessary to meet the College of Policing’s obligations in addressing the findings and recommendations of judicial and Home Office bodies.

3.2 Coroners’ Inquests

12. In Maughan, the Supreme Court held by a majority of three to two that at coronial inquests the standard of proof to be applied to the question of whether the deceased had died by suicide should be the civil standard, not the criminal standard, regardless of whether the conclusion was expressed by way of a short-form conclusion or a narrative conclusion.^{[footnote 4]}  This reversed the long-established historical position that the criminal standard applied to the short-form conclusions of suicide and unlawful killing. The principal reasons for upholding this change in the standard of proof as regards suicide were fourfold. First, that nothing in the common law or the Coroners and Justice Act 2009 demonstrated any cogent reason for disapplying the general principle that the civil standard of proof should apply in civil proceedings. Second, the criminal standard might lead to suicides being under-recorded and to lessons not being learnt. Third, the changing role of inquests and changing societal attitudes and expectations confirmed the need to review the standard of proof in cases of suicide. Fourth, leading Commonwealth jurisdictions had taken this course.

13. Although the decision in Maughan related to a death by suicide, the majority went on to determine that the civil standard of proof should also be applied at an inquest to the question of whether the deceased had been unlawfully killed, regardless of whether this was expressed by way of a short-form or narrative conclusion.

14. In support of the change from the criminal to the civil standard, it was highlighted that the criminal standard was historically considered necessary for a conclusion of unlawful killing in coronial proceedings on the basis that it was one of the mechanisms for establishing criminal liability. As Lady Arden observed in her judgment, it used to be the duty of the coroner’s jury when they found that the death was murder, manslaughter or infanticide, to state in the conclusion the name of the person who had committed the offence or who was an accessory before the fact.^{[footnote 5]} Section 56 of the Criminal Law Act 1977 implemented the important change that coronial conclusions must avoid finding that any particular individual is guilty of murder, manslaughter or infanticide (see also section 10 of the Coroner and Justice Act 2009). This change is said to have reduced the need for the criminal standard to apply to unlawful killing conclusions.

15. Otherwise, it was concluded that the civil standard should apply in all non-criminal cases, unless there is some good reason to the contrary; that there is no principled basis for distinguishing between suicide and unlawful killing in this regard; and that the criminal standard increases the likelihood of the jury returning an open conclusion, meaning that it will be unclear as to how the deceased came by his or her death, and what steps could have been taken to prevent it and how future deaths can be prevented. The majority in Maughan additionally relied on the contention that those implicated in coronial proceedings of involvement in an unlawful killing are at no greater risk of prosecution or identification than they would be if findings of fact had been made against them in civil proceedings. It was observed that the identity of the person responsible for the death will often be apparent. Lady Arden stated that “a common standard applying to both unlawful killing and suicide is more consistent with principle and removes an inherent inconsistency in the determinations made at an inquest. It reflects the general rule for the standard of proof in civil proceedings”.^{[footnote 6]}

16. Lord Reed (President) and Lord Kerr dissented. Focusing on their consideration of unlawful killing, they concluded that Note (iii) to Form 2 of the Coroners (Inquests) Rules 2013 gave statutory expression to the common law rule that “(t)he standard of proof required for the short form conclusions of ‘unlawful killing’ and ‘suicide’ is the criminal standard of proof. For all other short-form conclusions and a narrative statement the standard of proof is the civil standard of proof”.^{[footnote 7]} Furthermore, the minority were of the view that there was no inconsistency between the different standards of proof for the short- form conclusion and the narrative statement given the latter “[…] recounts the salient evidence and circumstances. In the case of unlawful killing and suicide it should not purport to constitute a final conclusion on that evidence unless the coroner or the jury has become convinced beyond reasonable doubt that it is justified”.^{[footnote 8]}

17. The minority determined, therefore, that “what the 2013 Rules unquestionably established was a statutory basis for the application of the criminal standard of proof for conclusions (or short form conclusions) in cases of suicide and unlawful killing and that statutory imperative cannot be displaced by judicial pronouncement. It has full force and effect until amended or abolished by subsequent statutory provision”.^{[footnote 9]}

18. It was stressed by the minority that inquests are neither criminal nor civil in nature but instead they are sui generis proceedings with rules of procedure of their own.^{[footnote 10]} They highlighted that, in any event, the characterisation of the proceedings as civil or criminal will not automatically predetermine the standard of proof to be applied. Instead, on the basis of a substantial body of authority, if “the proposition which is sought to be established is sufficiently grave or carries significant consequences for those whom it will affect, the criminal standard of proof may be deemed to be appropriate”.^{[footnote 11]}

19. Finally, they expressed the view that a short-form conclusion that the deceased’s death in a particular case was the result of, for instance, accident, misadventure, natural causes or a road traffic accident will ordinarily not carry the significance that they were unlawfully killed. As Lord Kerr suggested on behalf of the minority, “the latter verdicts denote a solemn pronouncement and they have clear resonances beyond those of other short form conclusions”.^{[footnote 12]}

4. The Approach adopted to the Rapid Review

20. We have had the advantage of access to the relevant materials gathered for the PAR, and we have invited wide-ranging submissions from, and have met with, those representing a broad range of opinions, as summarised below. We have also considered the core submissions advanced to the Supreme Court in Maughan and W80.

21. The written materials have included the following (we have added a short summary of the principal submissions as relevant to this Review); we stress, however, that this list is not exhaustive:

i. “The Review of Police Disciplinary Arrangements: Report” dated January 2005. This Review was led by William Taylor CBE QPM (a former Commissioner of the City of London Police and former HM Chief Inspector of Constabulary for Scotland) (“The Taylor Review”). The apparent core intention of the Taylor Review recommendations was “to encourage a culture of learning and development for individuals and/or the organisation. Sanction has a part, when circumstances require this, but improvement will always be an integral dimension of any outcome” and that “The language and environment for handling police discipline should be open and transparent. It should be much less quasi-judicial. Investigations need not be centered on the crime model, the style of hearing should be less adversarial and similarities with a ‘military court marshal model’ avoided”.^{[footnote 13]} The Taylor Review, although it set the scene for the changes to the police disciplinary arrangements which were implemented thereafter, did not refer to, or make recommendations about, the competing civil and criminal law tests for the purposes of addressing an honest but mistaken belief in misconduct proceedings. Nor, in our assessment, can an implied preference for either of these tests be discerned from the Review. In considering how “sanctions” should be addressed in the future, this simply did not arise for consideration.

ii. “The Metropolitan Police Service Submission to the Home Office in support of the Police Accountability Review 2023” (undated). It was recommended that an amendment should be made to the wording of the Use of Force standard of the Standards of Professional Behaviour contained in Schedule 2 to the Police (Conduct) Regulations 2020 to the effect that the test to be applied in disciplinary proceedings in relation to the use of force by a police officer in self-defence and in defence of others is the subjective criminal law test. Furthermore, it was recommended that the standard of proof for unlawful killing in coronial proceedings should be returned to the criminal standard of proof.

iii. The “Submissions from the National Police Chiefs’ Council”  to the 2023 PAR dated 17 October 2023. The NPCC emphasised that “Police officers accept significant risks to their own safety. They are called upon to use force often in the course of their duties where they, their colleagues or members of the public are at risk of attack from a third party. They are frequently required to step forward and deal with situations that others would step away from, to confront risks in often uncertain situations to protect the public. In those, often split-second, decisions, officers should – in the interests of public safety as well as their own safety – have the confidence to be able rely upon their training”.^{[footnote 14]}

They additionally recommended (i) that the criminal law test for self-defence should apply in police misconduct proceedings for breach of the Test of Use of Force in all cases or, failing that, in cases where lethal weapons are discharged by police officers; and (ii) that the criminal law test for self-defence should apply in inquests.^{[footnote 15]} It was stressed that adopting the civil law test for use of force in misconduct proceedings will undermine the recruitment and retention of armed officers given the concern by police officers, who volunteer for firearms roles, of the risk of adverse consequences from discharging a firearm when they honestly believed it was necessary to do so but that belief turns out to have been mistaken and not objectively reasonable. Data from armed policing (from April 2019) demonstrates the start of a “slow decline” in those wishing to serve as armed officers. The Armed Policing Attrition and Retention document records that since that date there has been a loss of 583 armed officers, or a 8.8% reduction. It was emphasised that police officers volunteer for armed roles and they are not compelled to undertake such duties.

The NPCC submitted that the criminal standard of proof (beyond reasonable doubt) and not the civil standard of proof (the balance of probabilities) should be used in inquests and other relevant inquiries for a finding of unlawful killing, whether as a short-form or narrative conclusion. It was suggested this could be achieved by amending the Coroners (Inquests) Rules 2013. The NPCC highlighted the differences between coronial and civil proceedings (e.g. the latter are usually brought against the Chief Constable, the local policing body pays any damages, the finding in a civil trial is not framed in terms of a homicide/unlawful killing, and the level of publicity is usually far higher at an inquest).

iv. “The NPCC Engagement Session Report” dated 17 October 2023, in which it was highlighted that officers are fearful of the consequences and processes for them if they are involved in a death or serious injury case because of what has happened to colleagues, more so by how it plays out in the media.

v. “NPCC Submissions to Sir Adrian Fulford PC and Tim Godwin OBE QPM on their review of the Supreme Court judgements of relevance to the Accountability Review”

The NPCC’s arguments described above were further emphasised and developed.

vi. “The IOPC submission to the Home Office’s Review of Investigatory Arrangements which follow police use of force and police driving related incidents” to the 2023 PAR dated November 2023, in which strong support was given to the judgment in W80 on the basis that when misconduct proceedings occur “they are able to consider whether a person is suitable to serve as a police officer or whether their conduct was such that they should be removed from the service”.^{[footnote 16]} It was stressed that as of November 2023, of the last ten fatal police shootings for completed investigations, two resulted in officers being investigated for potential misconduct relating to the use of force, and one met the test for criminal investigation. In the others, the principal firearms officer was treated as a witness throughout the investigation. Of the 312 investigations completed by the IOPC in 2022/23, only 115 (37 per cent) involved a conduct matter. In the rest, officers were treated as witnesses. In the same timescale, 87 misconduct proceedings took place following an IOPC investigation and in 80 per cent of these there was a finding of misconduct or gross misconduct.^{[footnote 17]} It was suggested that if the criminal law test is applied, “officers who used force (possibly repeatedly) on the basis of unreasonably mistaken beliefs would remain undisciplined and potentially continue in service”.^{[footnote 18]} Furthermore, the standard of proof of a balance of probabilities is “common to almost all regulatory and civil proceedings”.^{[footnote 19]} It was emphasised that “not being able to dismiss an officer who may have repeatedly used excessive force on the basis of unreasonable beliefs about the factual circumstances would undermine public confidence”.^{[footnote 20]}

Following our meeting with the IOPC, David Emery, General Counsel, at the IOPC, helpfully sent through additional material which has been taken into account in our conclusions.

vii. “The Inquest and Inquest Lawyers’ Group response to the Home Office’s Review of Investigatory Arrangements which follow police use of force and police driving incidents” to the 2023 PAR dated 17 November 2023. It was submitted that “the consequences of applying the criminal test would mean a small but important class of cases (including allegations of the discriminatory use of force) may escape public scrutiny and accountability. This would adversely affect public confidence in the police, particularly in light of the disproportionate police use of force on Black and racialised people. For example, an officer may have an honest belief that a person poses a threat which is discriminatory, for example by being based on unconscious bias or racial stereotyping that views Black men as more dangerous than White men. In such a case, under the criminal test, the discrimination is not directly relevant and will normally be overlooked”.^{[footnote 21]} As regards coronial proceedings, it was argued that there is no lawful or principled basis for suggesting that the criminal standard of proof was required, a standard which would “impede the ability of inquests to establish the full circumstances of what led to someone’s death”.^{[footnote 22]}

viii. “The coroner and the quantum of Proof” by Paul Matthews, Journal Article, Civil Justice Quarterly C.J.Q. 1993, 12 July, 279-289 (together with a Postscript) in which it was argued that England and Wales should follow the Ontario Court of Appeal in Re Beckon (1992) 93 D.L.R. (4th) 161 wherein the court concluded that the test for proof of a “serious allegation such as one of suicide” was “not proof beyond a reasonable doubt but, rather, proof to a high degree of probability”.

ix. “The Amended Defendant’s Skeleton Argument” dated 1 July 2019 submitted to the Administrative Court in W80, the “Appellant’s Skeleton Argument” dated 10 January 2020 submitted to the Court of Appeal in W80 and the “Written Case for The Independent Office for Police Conduct” dated 27 January 2023 submitted to the Supreme Court in W80 (all by Tim Owen KC et al). It was submitted that the test for the assessment of an officer’s use of force should be “consistent with the civil law test for self-defence in that it requires an objective assessment of all the circumstances and imports a requirement for an officer’s belief as to the necessity of their use of force to be reasonable. This objective test upholds the threefold purpose of the police misconduct regime, namely, to maintain public confidence in and the reputation of the police service; to uphold high standards in policing; and to deter misconduct”.^{[footnote 23]}

x. “Written Case for the Commissioner of Police of the Metropolis” in W80 dated 27 January 2023 by Jason Beer KC and Robert Cohen.

xi. “Written Submissions of the Chief Coroner” dated 3 February 2020 by Jonathan Hough KC in Maughan. These have particularly assisted us in reaching certain of our conclusions as set out below.

xii. “Inquest’s Written Case” dated 3 February 2020 by Adam Straw, “Submissions by Inquest and Stopwatch” dated 17 February 2023 by Adam Straw KC and Jesse Nicholls and leading counsel’s “Speaking Note” in Maughan. Principally, it was submitted that “The main relevant purposes or functions of an inquest are to determine how the deceased died, to bring culpable conduct to public notice, to determine whether lethal force was justified, the prevention of future deaths, and to meet the legitimate expectations and concerns of the family and wider public. The inquest is partly inquisitorial and has relaxed rules of evidence. The consequences of a conclusion for a killer are limited because he or she may not be identified, and the conclusion has no legal effect. Those consequences must be balanced against the legitimate interests of the deceased, the family, and the wider public, for whom there may be substantial adverse consequences of getting the conclusion wrong. Having different standards of proof is contrary to the interests of clarity and consistency”.^{[footnote 24]}

Furthermore, it was argued that the police use of firearms constitutes only a “tiny fraction” of the number of incidents concerning the police use of force generally and that by importing the criminal test would have adverse consequences, including by undermining public confidence in areas of policing, such as the discriminatory use of force, which are of substantial and enduring public concern. It is suggested there would be a “small but important class of cases (including allegations of the discriminatory use of force) in which police misconduct escapes public scrutiny and accountability”.^{[footnote 25]}

Key submissions on behalf of Inquest included the contentions that Article 2 of the European Convention may be engaged in inquests; the purposes of coronial proceedings include, insofar as possible, the need to bring culpable conduct to public notice; and that if the criminal standard is applied, the primary purpose of the inquest to determine how the deceased died and (in relevant cases) whether the killing was unlawful will be undermined. It was suggested it will become “more likely that the inquest will overlook cases of unlawful killing than if the balance of probabilities was applied”.^{[footnote 26]} Furthermore, the decision on unlawful killing may be inter-dependent with other conclusions that are subject to the civil standard of proof.

xiii. “Statement of Case of the Appellant” in Maughan dated 14 January 2020 by Karon Monaghan QC and Jude Bunting, the “Further Written Submissions of the Appellant” dated 22 June 2020 by Karon Monaghan QC and Jude Bunting, the “Skeleton Argument of the Appellant” in the Court of Appeal dated 11 September 2018 and the “Skeleton Argument of the Claimant” dated 17 June 2018 by Jude Bunting. In short, it was submitted that “For decades it had been held and presumed that in cases of unlawful killing and suicide the standard of proof applicable was the criminal standard; that is, “beyond reasonable doubt”. There are sound reasons for affirming this approach. It reflects the long-established view of the Courts that suicide should not be inferred from insubstantial evidence. It avoids unnecessary findings that cause serious social, economic and other consequences to families who have only a limited opportunity to shape the development of argument. It provides the protection to families that the procedural rules do not. It avoids confusion and undue complexity in proceedings frequently determined by a jury. It avoids any inconsistency with the approach adopted in unlawful killing cases”.^{[footnote 27]}

xiv. “Statement of Case of the Respondent” in Maughan dated 28 January 2020 by Alison Hewitt, in which the Respondent (HM Senior Coroner for Oxfordshire) took a neutral stance on the question of the standard of proof to be applied in coroners’ courts in relation to the short-form conclusion of “suicide”.

xv. Letter from the National Black Police Association dated 24 October 2024 to the Home Secretary opposing the suggestions advanced by the National Police Chiefs’ Council in this context (see above), on the basis that they represent a dilution of accountability on the use of force and driving standards. It was highlighted that only Metropolitan Police Service officers had handed in their firearms following the charging of Sergeant Blake and it was submitted that “As a body that represents the views and experiences of Black, Asian and Minority Ethnic officers and staff we are deeply concerned that each time policing pushes back on accountability, it often involves behaviour from our white ethnic majority colleagues towards Black, Asian and Minority Ethnic communities”.

xvi. “The Independent Report on behalf of the Police Federation in regards to the Home Office’s published Terms of Reference for a Review into investigatory arrangements which follow police use of force and police driving incidents” dated 17 November 2023 by Dean George KC. This provided useful background but it did not add materially to our analysis of the principal issues we have been asked to consider.

xvii. “When Things Go Wrong” a Report by Justice dated 2020 prepared by a Working Party under the Chair, Sir Robert Owen. This provided useful background but it did not add materially to our analysis of the principal issues we have been asked to consider.

xviii. “Submissions of Inquest, Police Action Lawyers Group, Inquest Lawyers’ Group, StopWatch, and Centre for Women’s Justice” to the Rapid Review dated 6 December 2024 in which it was argued that “There is no credible, let alone compelling, case for the legislative change under consideration and this Review should reject the proposals. If the Review considers itself unable to do so, then further consultation will be necessary. Given the fundamental changes under consideration – which have implications well beyond the sphere of policing – that consultation process must be detailed, extensive, and wide-ranging, and have a reasonable time period to allow meaningful engagement”. It is further argued that that “the development of the law (following Maughan and W80), arising from careful judicial consideration at the highest level of questions of law, public policy and the public interest, has provided appropriate legal tests”. The suggestion was made that the legal and policy implications of the proposed change would be very wide-ranging, creating the need for extensive consideration and consultation. Examples of cases demonstrating those likely to be affected are helpfully set out. The victims of violence against women and girls, along with black and minoritised women, are likely to be particularly adversely harmed by the suggested change.

It was additionally argued that changes in the two areas being considered by the Rapid Review would be inappropriate given the conclusions of Baroness Casey in her ‘Independent Review into the Standards of Behaviour and Internal Culture of the Metropolitan Police Service’ (“the Casey Review”) published in March 2023

which noted elitist attitudes and toxic cultures of bullying, racism, sexism and absenteeism, and that normal rules do not seem to apply or be applied in MO19, the specialist firearms unit.^{[footnote 28]}

xix. A letter from the Association of Police and Crime Commissioners dated 10 October 2023 to the Home Secretary in response to the 2023 PAR. This provided useful background but it did not add materially to our analysis of the principal issues we have been asked to consider.

xx. “Achieving Racial Justice at Inquests, A Practitioner’s Guide” dated 21 February 2024, published by Inquest.

22. We had meetings with the following individuals, during which others attended:

• Chief Inspector Andrew George (Police Service of Northern Ireland and President of the National Black Police Association)

• HH Judge Alexia Durran, the Chief Coroner of England and Wales and Cathy Yallop, Legal Adviser to the Chief Coroner

• Chief Constable Sir Andy Marsh, Chief Executive at the College of Policing

• Detective Chief Superintendent Michael Allen of the Greater Manchester Police (Head of Professional Standards Directorate) and Staff Officer to the NPCC Professional Standards & Ethics and Complaints & Misconduct portfolios

• Fiona Rutherford, Chief Executive, and Tyrone Steele, Deputy Legal Director, at Justice

• Rachel Watson, Director General, and David Emery, General Counsel, at the Independent Office for Police Conduct

• Charlie Hall QPM, former Chief Constable for Hertfordshire Constabulary and Chair of the Operations Co-ordination Committee for the NPCC and currently the Strategic Advisor to the Police Federation

• Pippa Mills, Assistant Commissioner, Met Operations and Performance, at the Metropolitan Police Service

• B J Harrington QPM, Chief Constable of Essex Police and Chair of the Public Order Public Safety (“POPS”) NPCC portfolio

• Deborah Coles, Executive Director at Inquest and Daniel Machover, Partner at Hickman and Rose solicitors and leader of the Inquests and Public Inquiries Team

• Amy Rees, Director General Chief Executive HM Prison and Probation Service

• Assistant Commissioner Matt Twist at the Metropolitan Police Service responsible for frontline policing

• Sir Mark Rowley, the Commissioner of Police of the Metropolis

• Dame Lynne Owens DCB, CBE, QPM, DL, Deputy Commissioner of Police of the Metropolis

• Abimbola Johnson, barrister and Chair of the Independent Scrutiny and Oversight Board which provides overview and external scrutiny of the Police Plan of Action on Inclusion and Race

• Nicholas Moss KC, who provided extensive independent advice on the central issues addressed in this Review (at our request)

• John Beggs KC, who provided independent advice on the Review (at our request)

• Matthew Butt KC, who provided advice on behalf of the Metropolitan Police Service

• Fiona Murphy KC, who provided advice, as a member of the Inquest Lawyers’ Group

• Gerry Boyle KC, who provided independent advice on the Review (at our request)

23. Prior to submitting the final version of this Review to the Home Secretary and the Secretary of State for Justice, with their consent we provided focused questions on the main emerging themes of the Review to those set out in the preceding paragraph, prior to reaching our final conclusions. We had originally intended to provide these bodies and individuals with a draft version of the Review as part of this exercise, in particular because we had originally and incorrectly anticipated that our conclusions would be influenced to a large extent by statistics concerning trends prior to and post Maughan and W80. This turned out not to be the case, and, as set out below, this has been principally an exercise in evaluating competing contentions on questions of policy, on which we have reached conclusions. It seemed to us in those circumstances to be disproportionate to build in a second substantive round of consultation in which we offered up our preliminary conclusions for debate, particularly in the context of a “rapid” Review. Therefore, we adjusted our approach and the questions were formulated in a manner that revealed many of the key considerations which have influenced our recommendations. We anticipated it would be helpful to invite submissions on these factors, particularly when they had not necessarily previously been highlighted or addressed in the first round of meetings. The responses we received to these questions, both in writing and during the second round of meetings which we organised, were of particular assistance to our work. The process of inviting further written submissions and holding two rounds of meetings meant that the Review took three months longer than we had originally anticipated.

5. Conclusions

The threshold for determining a short-form conclusion of unlawful killing in inquests

24. It has been emphasised in the submissions we have received that an individual suspected of responsibility for a death in these circumstances is currently placed in the invidious position of potentially facing a) a criminal trial in which the charging decision by the CPS and the jury’s conclusion are based on the criminal test for self-defence/defence of others and in which the standard of proof which must be met in the Crown Court is beyond a reasonable doubt; b) misconduct proceedings in which the decision of the IOPC (if it directs that misconduct proceedings should be brought) and the decision of the Panel at the conclusion of the misconduct proceedings, are both made applying the civil law test for self-defence/defence of others; the conclusions of the Panel, moreover, are reached on the balance of probabilities rather than the criminal standard beyond a reasonable doubt and c) a coroner’s inquest in which the standard of proof for the short-form conclusion is on a balance of probabilities.

25. This results in, first, the potential for seemingly inconsistent results depending on the nature of the proceedings (what John Beggs KC vividly described to us as a “mishmash of jeopardies”); second, the concern by police officers that although they may instinctively and honestly believe that the use of force is necessary, they additionally need to ensure that they are not relying on a potential mistake of fact which, when objectively assessed, may be considered to be unreasonable; and, third, although the officer may have been acquitted of homicide at the conclusion of a criminal trial (applying the criminal standard of proof), the coronial proceedings (applying the civil standard of proof) may return a conclusion of unlawful killing. It is likely that the police officer’s identity will be known throughout these proceedings.

26. By way of an example, on 29 November 2016 Lewis Skelton was fatally shot by an armed police officer in Hull City Centre. Mr Skelton, brandishing an axe, advanced towards members of the public. A police taser was used but proved ineffective. The Independent Police Complaints Commission (“IPCC”) investigated the shooting and in November 2017 found no indication of misconduct or a criminal offence. The relevant officer was treated as a witness. The IPCC did not, therefore, consider disciplinary proceedings or refer the case to the CPS. No learning recommendations were made. As a result of the changes brought about by Maughan, and despite the conclusions of the IPCC, at an inquest nearly four years later a coroner’s jury concluded that Mr Skelton had been unlawfully killed by the officer. Although the IOPC (the successor in 2018 to the IPCC) decided not to reinvestigate, that decision was overturned by the High Court. On 18 September 2024 the IOPC announced its decision to re-open their investigation. We apprehend there is a significant risk of confusion on the part of members of the public as between the criminal and the civil standards of proof in this context, resulting in pressure inappropriately being brought to bear on the IOPC to determine there is an indication of a criminal offence and to refer the matter to the CPS, and for the latter to instigate criminal proceedings against the officer, despite the IOPC’s decision having been made applying the lower civil standard. We note that this appears to have been the first inquest in this context to have taken place since the decision in Maughan. A final outcome to these overall proceedings is still pending eight years after the original incident.

27. Although it is difficult to calculate the position with precision, from the extensive research we conducted we apprehend that the possibility of being the subject of multiple proceedings in the manner set out above has had a seriously adverse effect on the morale of a significant number of serving officers, most particularly those with (or who are contemplating taking on) firearms responsibilities.

28. Not least because of the distinction of the members of the court, it would be inappropriate for the authors of this Review to engage in a general critique of the conclusions of the majority in Maughan, including, importantly, as to whether the decision has had the effect of impermissibly overriding a statutory provision.^{[footnote 29]} We stress, nonetheless, that the section of the principal judgment of the majority (that of Lady Arden, with whom Lord Wilson agreed) in which unlawful killing was addressed was confined to a few short paragraphs,^{[footnote 30]} in which disagreement was expressed with the analysis of Davis LJ in the Court of Appeal on this issue ([2019] EWCA Civ 809; [2019] QB 1218 at [90] et seq.).^{[footnote 31]}

29. Apart from the submissions of counsel, the members of the Supreme Court in Maughan seemingly had no material before them as to the suggested benefits, or indeed the disadvantages, of the changes which the judgment sought to uphold, following the decision of the Court of Appeal (certainly none to which reference is made in the judgment). During this Review, we have not been made aware of any indications that the status quo ante had created any identifiable difficulties in coroners’ courts when applying the criminal standard of proof in cases involving a potential conclusion of unlawful killing. In this regard, we were particularly impressed by the views of the current Chief Coroner, which are to the effect that a return to the criminal standard of proof for unlawful killing is unlikely to be controversial with coroners in England and Wales and that, prior to Maugham, applying different burdens had not been problematic for coroners or juries.

30. Indeed, the jury directions relating to unlawful and lawful killing were considered in R (Duggan) v Her Majesty’s Assistant Deputy Coroner for the Northern District of Greater London [2017] EWCA Civ 142, during which case no suggestion was advanced that the criminal standard of proof causes difficulty. It did not form part of the majority’s reasoning in Maughan that a change was required due to confusion over the standard of proof. It is, furthermore, a common feature of criminal trials that the civil standard applies when a reverse burden is imposed on the defence, and we note that there has been no substantiated suggestion that juries are liable to be confused by a route to verdict which applies both standards.

31. The Chief Coroner’s Office highlighted the official annually published Ministry of Justice figures which include the number of unlawful killing conclusions reached in each of the last seven years which are as follows:

Year	No. of unlawful killing conclusions in England and Wales
2017	109
2018	94
2019	135
2020	61
2021	101
2022	98
2023	59
2024	89

32. It needs to be said immediately that these figures are of little assistance for present purposes because they capture all unlawful killing cases and not just those involving the use of force by police officers. Furthermore, additional care is required in interpreting these figures because of the impact of the Covid-19 pandemic on the hearing of longer, complex inquests, especially those before an inquest jury. These impacts of Covid-19 may mean that relatively fewer cases involving consideration of a conclusion of unlawful killing will have been finalised each year since the decision of the Supreme Court in Maughan than would have been the case pre-pandemic. We note, nonetheless, the 40% reduction in unlawful killing conclusions between 2022 and 2023. However, bearing in mind the figures from 2024, perhaps the most that can properly be observed is that, thus far, there has been no noticeable effect on the overall number of unlawful killing conclusions, bearing in mind particularly the element of annual variation going back to 2017. At this point in time, therefore, there is no evidence that the changes implemented by Maughan have helped families or the public to gain a better understanding of how the deceased came by his or her death and what could have been done in the case, or what could be done in the future, to prevent a recurrence, as envisaged by the majority.^{[footnote 32]}

33. In this context we stress that the representations we have received demonstrate that individuals, groups and organisations concerned with the unlawful use of force by police officers, including in particular those concerned at its potential disproportionate impact on minority ethnic groups, viewed the anticipated increased likelihood of a renewed inquest as a clear advantage of the decision in Maughan. Put shortly, an acquittal of a police officer in the criminal courts post Maughan is suggested to pose less of a bar than before to a resumed inquest, which, in turn, will be able to provide further scrutiny of the reasonableness of the force used by the officer. Lady Arden suggested that if the criminal standard continued to be applied, it “would appear to the public as if the system has conspired to prevent the truth from being available to them”.^{[footnote 33]}

34. Although these arguments are readily understandable, we respectfully suggest they are based on a fundamental misconception. With a proper appreciation of the governing provisions - an appreciation which is especially necessary on the part of coroners - a return to the criminal standard of proof for the short-form conclusion of unlawful killing should not entail less scrutiny than under the civil standard. This is because the test for the resumption of an inquest after a homicide acquittal (or indeed conviction) is whether there is “sufficient reason” to resume the inquest. The decision by the coroner’s court as to whether there is sufficient reason to inquire into the use of force and whether it was appropriate or suitable (usually avoiding the description “unreasonable”) is not in any sense dependent on whether there is a change back to the longstanding criminal standard of proof as regards the short-form conclusion of unlawful killing. The jury in the future, just as at present and in the past, will be able to make findings, including critical findings in box 3 (the brief factual findings) and/or by way of a narrative conclusion in box 4 (the conclusion).

35. For example, if an officer has been acquitted in a homicide trial and the criminal standard of proof applies for unlawful killing at the resumed inquest, an inquest jury could still find on a balance of probabilities: (a) that the officer was mistaken as to the factual circumstances and (b) that the officer’s view of the circumstances was inappropriate. Article 2 permits an inquest jury to reach such a judgment in a narrative conclusion. Although this proposition has not been tested in the courts, we are confident that the law would permit such conclusions being included in the Record of Inquest by way of findings in box 3 and box 4, notwithstanding the unavailability of a conclusion of unlawful killing because the officer had been acquitted of a homicide offence in the Crown Court. Accordingly, the argument that the inquest would have notably less opportunity to scrutinise and make findings about the appropriateness of the use of force is, in our respectful view, erroneous.

36. Equally, while the point has not been fully tested in the courts, we consider that it would remain open to the jury to include in a narrative conclusion (to the civil standard) that the officer’s view was not honestly held, given such a finding does not contain all the elements, established to the criminal standard, which would be necessary for a homicide conviction. Such a finding would not, therefore, be inconsistent with the outcome of the criminal trial. Critically, such a narrative conclusion would be a wholly different outcome from “unlawful killing”, which indicates that one of a limited number of homicide offences has been committed.

37. It follows that whilst some of these issues may be litigated in the courts, it seems to us the criminal standard of proof for unlawful killing should not in any appreciable manner reduce coronial scrutiny, given the opportunities for findings to be made in the narrative conclusion. Indeed, it is critical that the coroner’s jury is able to make findings about the appropriateness of the use of force in a narrative conclusion because this will often be the trigger for the coroner’s decision to issue a Report to Prevent Future Deaths (a “PFD report”). Potential misunderstandings in this context may require additional guidance from the Chief Coroner.

38. Notwithstanding perceptions to the contrary, it is to be emphasised that the PFD report itself provides a further reason for concluding that the ability of a coroner’s court to address whether there are lessons to be learnt from what occurred is not in any sense dependent on the standard of proof to be applied in cases concerning an alleged unlawful killing. If during an inquest, a coroner becomes concerned about circumstances that create a risk of future deaths, the court must make a PFD report to the person or organisation that the coroner believes should take preventative action.^{[footnote 34]} Whether or not such a report is issued is not dependent on a conclusion of unlawful killing. This further underscores what we consider to be a fundamental misapprehension that a return to the criminal standard of proof would inhibit the opportunity for “lessons to be learnt” during coronial proceedings.

39. With due deference, an additional notable problem with the decision in Maughan is that coronial proceedings are not civil proceedings, a factor particularly relied on by Lady Arden and Lord Wilson. We conclude they are instead sui generis, particularly bearing in mind their inquisitorial nature. Addressing Mr Straw’s submission in the Supreme Court that “the civil standard should apply in all non-criminal cases, unless there is some good reason to the contrary”, we concur with what we consider to be the persuasive view of the minority in Maughan that “the characterisation of proceedings as criminal or civil will not automatically predetermine the standard of proof to be applied. If the proposition which is sought to be established is sufficiently grave or carries significant consequences for those whom it will affect, the criminal standard of proof may be deemed to be appropriate”.^{[footnote 35]}

40. Bearing in mind the entirety of the material that we have considered in this Review, we agree with the minority in Maughan that a finding of unlawful killing is of sufficient gravity to justify distinguishing it from other causes of death in terms of the level of proof that is required. We are wholly persuaded that it merits being placed in a “special category” in which proof is required to the criminal standard.^{[footnote 36]} A decision of this importance, with all the adverse attendant consequences, should not be made simply on the basis of what is more probable. It is, in the words of Lord Kerr, a “very serious matter”.^{[footnote 37]} The impact of social media, along with the other multiple means by which digital information is rapidly disseminated, means that the identities of those to whom conclusions of unlawful killing relate are likely to be widely known. Furthermore, following the decision of Fordham J in Glaister & Anor, R (On the Application Of) v HM Assistant Coroner for North Wales (East and Central) [2025] EWHC 167 (Admin), it remains permissible to include descriptions of relevant individuals by reference to their role or actions (e.g. as the driver of a particular car or as an Assistant Scout Master), in the findings of fact in box 3 and for a coroner to invite the jury to include descriptions – including the relevant role – within its conclusion in box 4 (see also Jervis on Coroners 16th Edition at 13-57). The reputational and other effects for the person thereby “identified” can be profound. For police officers, at the very least there may be considerable public pressure to open or reopen police disciplinary proceedings and for the CPS to review the decision not to charge the individual with a criminal offence if a prosecution has not already occurred.^{[footnote 38]} As we have already described, this can result in multiple proceedings for the person who is said to be liable for the death, lasting many years.

41. In our view it is not an overstatement to suggest that the individual (e.g. a police officer), as a consequence, will be viewed as a killer following a process which does not offer them the protections of a criminal trial, with the latter’s particular and more restrictive rules of evidence. At an inquest they do not have the right to call witnesses or to address the tribunal on the facts. When considering a conclusion of unlawful killing, the coroner’s court will be considering many of the concepts and principles applicable to the criminal law (e.g. the criminal law test of self-defence). We emphasise, moreover, that a conclusion of unlawful killing is a finding that one of a very few homicide offences has been committed (the court will have concluded that all the ingredients of the offence are present and that there was no lawful excuse - e.g. self-defence - for what occurred).

42. The conclusion of unlawful killing is not intended to contradict the principle that the function of an inquest is to establish the facts of the death without appearing to determine any form of legal liability (this latter requirement is secured, in particular, by providing that the court shall not name the individual responsible). The conclusion of unlawful killing has its origins in the ability of a coroner’s jury to perform the function of a grand jury and commit an individual for trial for a homicide offence. Parliament in the Coroners and Justice Act 2009 chose not to adopt a looser formula such as “traumatic death at the hand of one or more people” and instead, as just set out, prohibited any finding that appeared to determine the criminal or civil liability of a named person. As a consequence, relevant police officers will approach the coronial proceedings knowing that in all likelihood the family of the deceased will be suggesting that they were responsible for an unlawful killing. This will have a chilling effect on members of the police force generally, and others similarly placed (e.g. prison officers) notwithstanding the relatively small number of these cases.

43. These considerations, in our view, are a vital distinguishing factor for the particular conclusion of unlawful killing. It is notable that in R (Anderson) v HM Coroner for Inner North London [2004] EWHC 2729 (Admin) Collins J observed:

“21. An inquisition cannot identify any individual in a finding of unlawful killing. An inquest is not concerned to attach and is indeed expressly prohibited from attaching civil or criminal liability to anyone in particular. It is concerned only to determine who the deceased was and how, when and where the deceased came by his death. However, a finding of unlawful killing will almost inevitably be regarded as a condemnation of the actions of one or a number of easily identifiable persons.

It is presented in the media and regarded generally as a positive finding that that person or those persons between them have been guilty of a criminal offence, in this case, manslaughter. It is for this reason that the law requires that a verdict of unlawful killing be proved to the criminal standard: see R v West London Coroner ex p. Gray [1988] Q.B. 467.” (our emphasis)

44. It is apparent, we acknowledge, that the extended process we have described above only occurs in a small number of cases, but these are momentous events for the individuals to whom an unlawful killing conclusion relates. Within the police, this results, as we have already outlined, in an apprehension that split-second decisions, often made in fraught circumstances, can lead to multiple investigations resulting in seemingly inconsistent decisions. Careers are sometimes destroyed along with confidence amongst police officers that they will be treated fairly when they attempt to respond to a difficult situation on the basis of an instantaneous and honest assessment.

45. Reverting to our terms of reference, we consider, therefore, that there is a compelling case for immediate action as regards the standard of proof for the short-form conclusion as regards unlawful killing (bearing in mind the impact of the present position as regards police officers). We recognise the strength of feeling and the importance of the views such as those put forward by Inquest, the Police Action Lawyers Group, the Inquest Lawyers’ Group, StopWatch and the Centre for Women’s Justice. We have focused with care on their submissions, but it remains our clear view that the application of the higher criminal standard of proof to conclusions of unlawful killing need not (and should not) reduce the scrutiny of police action in the coronial courts.

46. Notwithstanding that conclusion, there remains a strong argument for wider consultation given the standard of proof for unlawful killing affects all kinds of cases, not just those involving contact with the police. Unlawful killing conclusions can arise (by way of example only) in cases involving the use of force in prisons and immigration custody, in medical cases, and following workplace health and safety fatalities. His Majesty’s Prison and Probation Service and the medical profession have indicated to us a strong wish to make full representations before a change is effected that would materially affect the interests of those they represent. There will be other groups beyond the scope of this Rapid Review whose interests are engaged.

47. We stress that we have not been asked to consider the position regarding suicide and we simply observe that there are likely to be wholly dissimilar considerations as between the two issues. We have proceeded on the basis that any change will simply concern unlawful killing.

48. Any change to the standard of proof for a conclusion of unlawful killing may well require primary legislation. There was a dispute in the Supreme Court in Maughan as to whether Note (iii) to Form 2 of the Coroners (Inquests) Rules 2013 had given statutory expression to the common law rule. Lady Arden and Lord Wilson considered that this was not the effect of Note (iii), which, we note, nonetheless remains unchanged (viz. “The standard of proof required for the short form conclusions of “unlawful killing” and “suicide” is the criminal standard of proof”). Lord Carnwarth (as the third member of the majority) agreed with the Divisional Court that “the power under section 45 of the 2009 Act to make coroners’ rules is sufficiently broad to enable a rule to be made stipulating the standard of proof to be applied in coroner’s proceedings. But if the intention had been to make such a rule, the appropriate place to do so would be in the body of the rules, and not in a prescribed form”.^{[footnote 39]} Although in our view there is a persuasive argument that the decision of the majority in Maughan impermissibly ignored a binding statutory provision,^{[footnote 40]} it is most probably necessary for there to be primary legislation in order to clarify the position, not least to avoid further protracted litigation.

The legal test for use of force in misconduct cases, and whether it should be raised to the criminal standard

49. The Supreme Court subjected the issue of the choice between the criminal and civil tests in this context to a clear and penetrating analysis. Nonetheless, we consider it necessary, with respect, to make a number of substantive observations. By way of essential background, as already indicated above, in 2004 the Secretary of State for the Home Department (the “SSHD”) commissioned a review of the arrangements for dealing with police misconduct and unsatisfactory performance. This was undertaken by William Taylor CBE QPM, who in January 2005 published the Taylor Review (see 21 i above). The recommendations of the Review were accepted and led to the Police (Conduct) Regulations 2008 (SI 2008/2864) (“the 2008 Regulations”). The successor 2012 Regulations, which applied in W80, were for present purposes identical to the 2008 Regulations. Lord Lloyd-Jones expressly indicated that the Taylor Review provided the core context for his interpretation of the 2008 Regulations, and that it heralded a “fundamental” change in relation to police conduct and disciplinary arrangements.^{[footnote 41]} This was reflected in the shift from a court martial model of disciplinary arrangements to new misconduct procedures based on the Advisory, Conciliation and Arbitration Service (“ACAS”) principles.^{[footnote 42]} Otherwise, the Supreme Court had in mind the decision in Ashley v Chief Constable of Sussex Police [2008] AC 962, which determined that the civil law test in relation to self-defence applied in civil proceedings (e.g. in a claim for the tort of battery), along with the provisions of section 76 of the Criminal Justice and Immigration Act 2008 (which provided that a defendant in criminal proceedings could rely on an honest and mistaken belief by way of self- defence even if the belief was an unreasonable one).

50. Critically, Lord Lloyd-Jones highlighted that the pre-Taylor Police (Conduct) Regulations 2004 (SI 2004/645) (“the 2004 Regulations”) established an appropriate test for police officers by reference to a Code of Conduct which was set out in a schedule. Under the heading “Use of force and abuse of authority” it provided that “Officers must never knowingly use more force than is reasonable, nor should they abuse their authority” (our emphasis). In contrast, the 2008 Regulations omitted the word knowingly and the new Standard of Professional Behaviour stipulated that “Police officers only use force to the extent that it is necessary, proportionate and reasonable in all the circumstances” (this wording has been replicated in the Schedules to the 2012 and 2020 Regulations).^{[footnote 43]}

51. In July 2014, the College of Policing issued, with the approval of the SSHD, a code entitled a Code of Ethics: A Code of Practice for the Principles and Standards of Professional Behaviour for the Policing Profession of England and Wales (“the Code of Ethics”). This had been recommended in the Taylor Review (see Executive Summary). The Code of Ethics was laid before Parliament under the Police Act 1996. The Code repeats the Standard of Professional Behaviour in relation to the use of force in the same terms as in the 2012 Regulations, but then elaborates this further by adding, inter alia, “You will have to account for any use of force, in other words justify it based upon your honestly held belief at the time that you used the force”.^{[footnote 44]} On 7 December 2023 the College of Policing published a Code of Practice for Ethical Policing “to complement a non-statutory Code of Ethics”.^{[footnote 45]} This has not provided additional assistance in determining the test to be used for “use of force”.

52. In summary, the Supreme Court relied on four key factors in deciding that the civil law test applied. First, it determined that the Standards of Professional Behaviour in the 2008 Regulations were framed as “statements of objective fact”.^{[footnote 46]} Second, the omission of the word “knowingly” from the 2008 Regulations was a “strong textual indicator” and “has a particular significance”.^{[footnote 47]} Third, the purpose of the disciplinary arrangements in the 2008 Regulations put “the true interpretation of the standard in respect of the use of force by police officers beyond doubt”, namely the shift to an employment model.^{[footnote 48]} And fourth, the purpose of maintaining confidence in the police was enhanced by the civil law test which “would not preclude the disciplinary process from considering the reasonableness of mistakes thereby enabling the disciplinary process to protect members of the public from police officers who make unreasonable mistakes”.^{[footnote 49]} The Supreme Court was of the view that applying the criminal law test meant that “the disciplinary process would be precluded from contributing to learning and development in relation to the reasonableness of mistakes. Quite simply, the criminal law test conflicts with the fundamental purpose of the disciplinary process being to contribute to learning and development for the individual officer concerned or for the organisation as to the reasonableness of mistakes”.^{[footnote 50]}

53. Lord Lloyd-Jones discounted the Code of Ethics as a means of statutory interpretation since it was published six years after the 2008 Regulations; its scope is limited to the discharge of the functions of chief officers; and the Code expressly refers to the formal wording of the 2012 Regulations in the context of misconduct proceedings.^{[footnote 51]} Lord Lloyd-Jones considered the Code to be wrong and misleading in this context and indicated that the Director General of the IOPC is obliged to follow the 2012 Regulations.^{[footnote 52]} A new Code of Ethics was published in 2024.

54. For the purposes of the present Review, we are not sitting in a court of law, and we have been able to focus on the issue of what the government intended when drafting the Police (Conduct) Regulations 2008 following the Taylor Review. We have carefully borne in mind the submissions of the IOPC, and in particular, first, that that the proper inference to be drawn from the removal of the word “knowingly” and its replacement with “reasonable in all the circumstances” is that, at least from 2008, it was clearly intended that an officer’s genuine but mistaken belief in the necessity for the use of force must be a reasonable one. And, second, that these changes broadly coincided with the passage of the Criminal Justice and Immigration Act 2008 which included provisions “to clarify and consolidate the common law’s position on the use of force in self-defence” and the decision in Ashley v Chief Constable of Sussex, which distinguished the criminal and civil law in terms of the subjective/objective approach to a defendant’s belief of imminent danger of attack.^{[footnote 53]} Notwithstanding these helpful submissions, we are unhesitatingly persuaded that whilst the wording of the use of force test was deliberately changed in 2008, this was not because it was intended that the test for self- defence in misconduct proceedings should shift from the criminal law to the civil law test. This would have comprised a fundamental change, on which, in our view, the government would undoubtedly have sought representations, a step which was not taken as part of the wider consultation which occurred. Such a move, furthermore, was simply not recommended or discussed in the Taylor Review, which was the genesis of these major changes to police misconduct proceedings as implemented in 2008. No reference was made to a new civil law test in the statutory guidance on police misconduct issued by the Home Office in 2008, which would have occurred if the move to the civil law test had been contemplated; similarly, the Explanatory Memorandum to the Police (Conduct) Regulations 2008, the Police (Performance) Regulations 2008 and the Police Appeals Tribunals Rules 2008 made no reference, at any stage, to this move from the criminal to the civil law test. Finally, the government gave no indication either in a public document or in communications with chief officers that such a change had been made. It is highly improbable that ministers would have intended to change something as important as the test by which use of force (including lethal force) by police officers was to be judged without any warning, given the critical need to enable updated training to take place and for guidance to be issued.

55. Adopting the IOPC’s suggestion that we should consider the best “lens” through which to assess the use of force by police officers in 2025 and going forwards, we turn to the argument that the lower civil law test enhances the prospects for “lessons to be learnt” (which was the subject of significant stress by the Supreme Court (see paragraph 52 above). In this regard, we highlight that an adverse finding against the officer is not in any sense a precondition for this to happen. There are various relevant stages in the processes which govern police misconduct investigations that can ensure this occurs without a finding of misconduct or gross misconduct.

56. By way of example for investigations under Part 3 of the Police (Conduct) Regulations at the regulation 14 “severity assessment” stage, the appropriate authority must assess whether the conduct, if proved, would amount to misconduct, gross misconduct or neither. If the appropriate authority assesses that the conduct would not amount to misconduct or gross misconduct it must then assess whether the conduct, if proved, would amount to practice requiring improvement, whether the matter should be referred to be dealt with under the Performance Regulations, or whether it should take no further action. At the conclusion of the investigation if the investigating officer provides an opinion under regulation 21(2)(c) that there is no case to answer the investigator may indicate that the matter be dealt with under the Performance Regulations or the reflective practice review process. Even if the matter is referred to misconduct proceedings the appropriate authority may withdraw those proceedings under regulation 27 but even then it may refer the matter to the reflective practice review process or refer the matter back to be dealt with under the Performance Regulations.

57. In cases involving death or serious injury, on receipt of an investigation report if the IOPC determines that the report does not indicate that a person serving with the police may have committed a criminal offence or behaved in a manner that would justify the bringing of disciplinary proceedings it may nevertheless notify the appropriate authority that it must determine whether any person’s performance is unsatisfactory and, if so, what action (if any) it will take. The IOPC can direct the appropriate authority that the performance was not satisfactory and what action should be taken in respect of it.

58. Ultimately, at the conclusion of any misconduct proceedings if it is determined under regulation 42 that the conduct amounts to neither misconduct nor gross misconduct, the person chairing or conducting the proceedings can direct that the matter is referred to be dealt with under the Reflective Practice Review Process.^{[footnote 54]} Curiously, there is no reference in regulation 42 to the possibility of directing that the matter be considered under the Police (Performance) Regulations 2020. We recommend that consideration is given to providing the same avenues for reviewing performance to i) the appropriate authority at the stages of the severity assessment and referral; (ii) the IOPC at the conclusion of an investigation and iii) the person chairing or conducting the misconduct proceedings if the allegation of misconduct or gross misconduct is not upheld.

59. The opportunities, generally, for reflective practice are varied. As the current Head of the Misconduct Hearings and Litigation Portfolio (“MHU”) within the Directorate of Professional Standards (“DPS”) has observed, a welcome reform to the misconduct procedures was introduced in February 2020 via Part 6 of the Police (Conduct) Regulations 2020, which contained provisions relating to reflective practice (the Reflective Practice Review Process (RPRP)). This was designed to refocus, wherever possible, police conduct upon resolution and solutions through learning. For cases finalised in 2023/24, almost half of the “conduct matter” allegations (43.47%) and almost a quarter of the “recordable conduct matter” allegations (21.46%) were dealt with through learning outcomes, including the Reflective Practice Review Process (RPRP).^{[footnote 55]} We are told that line managers have been encouraged to adopt a reflective approach to handling matters outside of the formal system so that, where a matter would clearly not amount to misconduct, it is dealt with locally with the officer concerned under the principles of reflective practice. We accept in this context the submission of the IOPC that the effectiveness of this process is reliant on proper engagement from both the individual and the manager.

60. Reflective practice under the present arrangements, therefore, can either be a relatively informal process outside of the police misconduct procedures or it can be action taken at the end of a misconduct investigation, meeting or hearing, as set out above. This is, therefore, a variegated landscape in which there are a number of different titles which are used to describe reflective practice and there is a degree of overlap between them. However, as a general rule, “learning through reflection” and “informal reflective practice” will normally relate to the process outside of misconduct procedures and the “Reflective Practice Review Process” (RPRP) will relate to more formal action taken under Part 6 of the Police (Conduct) Regulations. The view has been strongly expressed to us that the effect of the decision in W80 has been markedly negative in the sense that it makes it more likely that officers who have formed a mistaken belief will be subject to formal police misconduct procedures rather than immediately entering a process of reflection and learning.

61. We lay considerable emphasis, therefore, on the existence of other routes (in particular, police performance procedures, reflective practice and the review of authorisations for specific duties (e.g. for firearms officers and for pursuit driving)) by which action can be taken in appropriate circumstances. These would include when an officer uses force with a genuine and honest belief in circumstances where that view was both mistaken and unreasonable. We have been shown impressive individual examples of when this has happened.

62. It follows that we do not accept the argument that organisational learning is “lost” if misconduct proceedings involving the use of force revert to the criminal law test for the use of force in self-defence/defence of another. When the investigator assesses the purported honest belief of the officer, consideration will be given to whether it was reasonable in all the circumstances, not least because this will inform the decision as to whether the belief was honest. Furthermore, even if it is accepted that the belief was “honest”, it may be considered that the officer should undertake further training or that they should be removed from particular duties because of concerns, if established, of a tendency to make unreasonable assessments. There could, additionally, be proceedings under the Police (Performance) Regulations 2020 (viz. “unsatisfactory performance”) or a change to the particular Force’s training or guidance.

63. The IOPC indicates on its website:

“When we complete our investigations and reviews, we look out for opportunities to identify potential for learning, to improve policing at a local and national level. We also conduct independent research and collect statistical data helping us to identify issues early and make practical recommendations to influence change”.

64. The IOPC Statutory Guidance 2020 provides (at paragraph 4.6) that forces should ensure that there are robust procedures in place for identifying and acting on learning and should (amongst other things):

• Ensure that action is taken to implement any learning, including any accepted IOPC learning recommendations, as swiftly as possible. Where organisational learning is identified during the course of handling a matter, it is not always necessary to wait until the end of handling that matter before implementing any changes and improvements.

• Ensure that there are systems in place to record, monitor and report on the progress of action taken as a result of any learning.

• Ensure that any learning or good practice is shared with police officers and staff locally, where relevant, and incorporated into training and guidance as appropriate.

• Ensure that any learning or good practice is shared with other forces or partners working nationally, such as the College of Policing, where appropriate.

• Ensure that key stakeholders are informed when significant changes to policies or practice have occurred as a result of learning.

65. Furthermore, the IOPC has the power to make learning recommendations to the police. The first of these is via a recommendation under section 10 of the Police Reform Act 2002 which enables the IOPC to make recommendations concerning, for instance, police practice (this is referred to as a “quick time” learning recommendation) and it does not require a specific response. A Section 10 learning recommendation can be issued at any point by the IOPC whenever the necessity to do so becomes apparent and this is not predicated on a finding of misconduct. The second avenue is via a recommendation under Paragraph 28 A of Schedule 3 to the Police Reform Act 2002 which gives the IOPC the power to make recommendations (“learning recommendations”) on completion of specific investigations and reviews; a response is required within 56 days. These are directed at “organisational” learning.

66. We have considered a significant number of these “recommendations” and the responses to them, and they provide, in our view, a powerful tool for ensuring that lessons are learnt arising out of an incident in which force is used, wholly independently of any finding against an officer. By way of example, recently in what is called a “Consequence Management Input” (Command Refresher FT237), in the wake of an IOPC recommendation, the Metropolitan Police comprehensively addressed a number of complaints over the preceding 12 months resulting from individuals who had been stopped by armed police and who were either found to be unconnected to criminality or misidentified. Numerous recommendations were made as to assessing the impact of what occurred, holding appropriate debriefings, providing explanations and apologies, ensuring appropriate post-incident investigation, assessing the impact on local communities, and identifying the actions that should be taken. This is a strong contemporaneous example of how the police respond appropriately to incidents which have involved errors, in an attempt to address such events and to learn lessons for the future. For reasons of keeping this Review to a proportionate length, it is inappropriate to rehearse other examples of this process but its value should not be underestimated.

67. Finally, it is worth mentioning on this issue that as one of the mechanisms for addressing poor behaviour, including the inappropriate use of force, the Metropolitan Police established in October 2023 what are called Professional Standards Review Meetings, for which there is extensive guidance. These involve monthly meetings to identify and reduce risks of corruption to integrity within the Force and breaches of the standards of professional behaviour. Although this is not of direct relevance to the resolution of individual cases, it is a demonstration of how systemic concerns can be and are being countered.

68. We need next to address the submission that there may be cases where it is felt that disciplinary action is potentially required against officers who had formed what they maintained was an honest view of the circumstances in which force was used, but which was considered objectively to be unreasonable. In this context, we note particularly that Lord Lloyd-Jones emphasised in W80 the need for the disciplinary process to be able to protect members of the public from police officers who make unreasonable mistakes as to the facts.^{[footnote 56]} An example when this might arise would be if an officer assessed the circumstances as requiring force but this conclusion was infected by racial stereotyping.

69. In our view there are persuasive answers to this suggested problem which are not dependent on applying the civil law test. It is convenient, however, to turn first to the relevant decisions of the European Court of Human Rights in this context. In Armani Da Silva v The United Kingdom [2016] ECHR 314 the Grand Chamber approved an earlier decision in McCann and Others [1995] ECHR 31, which in turn reflected the approach which has consistently been applied by the court in this field. In summary, the use of force by agents of the State in pursuit of one of the aims in paragraph 2 of Article 2 of the European Convention on Human Rights may be justified when it is based on an honest belief which is perceived, for good reasons, to be valid at the time but which subsequently turns out to be mistaken. The Grand Chamber in McCann observed that to hold otherwise “would be to impose an unrealistic burden on the State and its law-enforcement personnel in the execution of their duty, perhaps to the detriment of their lives and those of others.”^{[footnote 57]} The Grand Chamber in Armani Da Silva set out that in the Article 2 cases in which the Court had addressed the question of whether a belief was perceived, for good reasons, to be valid at the time, it had declined to adopt the standpoint of a detached observer but instead it attempted to put itself into the position of the person who used lethal force.^{[footnote 58]} This was both when determining whether that person had the requisite belief and in assessing the necessity of the degree of force used. The court went on to observe that “If the belief was not subjectively reasonable (that is, it was not based on subjective good reasons), it is likely that the Court would have difficulty accepting that it was honestly and genuinely held”.^{[footnote 59]} In our view, this approach substantially answers Lord Lloyd-Jones’s concerns, and it provides a complete answer to the contention that reverting to the criminal test for self-defence for the use of force in misconduct proceedings would breach the enhanced investigatory obligation under Article 2. We accept, however, that these decisions by the Grand Chamber do not automatically mean that the criminal test for self-defence is the correct test to be used in police misconduct proceedings.

70. Turning against that background to the risk of racial stereotyping, given the training provided to police officers on this issue, a claim by the officer that he or she honestly held such an erroneous belief (especially one of significance) will, in all likelihood, simply be disbelieved. It is a misconception to suppose that an officer’s contention that he or she held an honest but objectively unreasonable belief will be accepted regardless of its implausibility. There is no basis for suggesting that such flawed arguments are accepted during disciplinary proceedings, and no evidence to this effect has been brought to our attention. Indeed, we are confident that the more unreasonable the suggested honest belief, the more likely it is that it will not be accepted as genuine. Moreover, in any misconduct proceedings there will be consideration of whether the force used was reasonable and proportionate on the basis of the honestly held belief. If it was unreasonable, the officer will be liable to sanction.

71. Were a police officer to rely upon an honestly held belief but there was a case to answer that it was based upon discrimination, they should face misconduct proceedings not just for breaching the standard of professional behaviour in relation to use of force but also for a breach of the professional standard of equality and diversity, and the appropriate authority would be expected to plead the case in this way. There may be direct evidence of racial stereotyping or the case against the officer could be based on unconscious bias. The presenting side could invite the misconduct hearing to make appropriate findings by applying an inferential approach (see Anya v University of Oxford [2001] EWCA Civ 405, [2001] ICR 847 and Nagarajan v London Regional Transport [2000] 1 AC 501, in which it was indicated that direct evidence of discrimination will seldom be forthcoming and usually this must be deduced, or inferred, from the surrounding circumstances). Notably, this approach was adopted in the misconduct allegations concerning the stop and search (including use of force) of Bianca Williams and Ricardo dos Santos. It was central to the IOPC’s case in that case that the officers were unconsciously discriminating and using force as a result of an honest but unreasonable belief. Under the Code of Ethics and IOPC Discrimination Guidance, this could amount to a breach of the standards of professional behaviour, potentially justifying dismissal, if proved, on the grounds of gross misconduct.

72. The potential for significantly protracted proceedings in which different tests are applied is not simply speculative. We recognise that in W80 part of the delay was a result of the challenge by W80 in the courts. Therefore, in addition to that case, the NPCC has highlighted, by way of a further example, the circumstances of NX1 and MY55. Following a non-fatal police shooting of a robber on 3 December 2018 in the Wimbledon area of London, two specialist armed officers, NX1 and MY55, were respectively charged with causing grievous bodily harm with intent and attempted grievous bodily harm with intent. As a consequence of a later review, the CPS offered no evidence against the officers on 11 October 2022, on the first day of their trial. The IOPC thereafter directed the officers’ force to conduct a gross misconduct hearing at which the officers were cleared on 3 May 2024. This meant that even without an inquest (given there was no fatality) the various Crown Court and disciplinary proceedings took 5 years 5 months from the date of the incident to the end of the misconduct hearing.

73. Finally, under this heading, we simply note in passing that the “indication test” is the definition of a “conduct matter”.^{[footnote 60]} Once a conduct matter is raised, the appropriate authority must separately make a “severity assessment” under rule 14 of the Police (Conduct) Regulations 2020. A “severity assessment” can result in no further action, referral to the Unsatisfactory Performance Procedure or referral to the Reflective Practice Review Process. Following the decision in W80, whenever there is simply an “indication” that an officer made an honest but objectively unreasonable assessment of the facts and the severity assessment is satisfied (e.g. bearing in mind the impact of what occurred), the officer must be dealt with under the misconduct procedures. Once misconduct is in this sense engaged, a notice of investigation must be served by the Directorate of Professional Standards. Particularly given the consequences that follows, the threshold of an “indication” is a notably low bar (it is lower than reasonable suspicion). For instance, once a notice of investigation has been served, consideration may be given as to whether to restrict or suspend the officer. Furthermore, the officer will be subject to the misconduct caution which is similar to the criminal law caution, with the effect that they do not have to say anything in connection with the investigation.

74. Reverting to our terms of reference, as with coronial proceedings and for the reasons set out above, we consider there is a compelling case for immediate action as regards the use of the civil test when considering an honestly held belief in misconduct proceedings. Furthermore, given the range of consultees with whom we have engaged, we respectfully question whether an extended period of consultation on this issue would serve any helpful purpose, subject to two matters which we highlight.

75. First, whilst a reversion to the position (at least) before the Taylor Review would logically apply to all cases involving the use of force by police officers, as in the coronial context we emphasise that this will not involve a step into unchartered territory. Instead, it will simply constitute a reversion to an earlier position. We are unaware of any evidence that applying the criminal test regarding an honestly held belief had created any difficulties or had been the subject of persuasive resistance until either the Taylor Review or the decision in W80. It goes without saying that it will be for the Home Secretary to determine whether there needs to be further consultation as regards a return to the criminal test in cases of fatal and non-fatal force following the decision in W80 in 2023. Similarly, it will be for the Home Secretary to determine whether any change should simply be confined to cases involving the use of fatal force. As to the latter, we question whether distinguishing between fatal and non-fatal force would be desirable: for instance, the issues arising in a serious case involving the infliction of grievous bodily harm and a case of manslaughter are likely to be the same or strongly similar.

76. Second, if the Home Secretary is minded to amend the Conduct Regulations, she is required by section 63(3)(a) of the Police Act 1996 to supply a draft of the suggested amended regulations to the Police Advisory Board for England and Wales, thereafter considering their representations.

77. If a change in accordance with our recommendations is to be made, we suggest that this could be achieved by an amendment to the wording of the Use of Force Standard within the Standards of Professional Behaviour in Schedule 2 to the Police (Conduct) Regulations 2020, to the effect that the test to be applied in disciplinary proceedings in relation to the use of force by a police officer (including in self-defence or defence of others, along with other circumstances arising during policing) is the subjective criminal law test. If this is to apply to fatal and non-fatal force, the drafting option we suggest under the heading Use of Force is “Police officers only use force when they honestly believe this to be necessary. The force used should be necessary, proportionate and reasonable”.

The Rt Hon. Sir Adrian Fulford

Tim Godwin OBE QPM

14 May 2025

1. Submissions from the National Police Chiefs’ Council, 1.1. ↩

2. The Jermaine Baker Public Inquiry: Report into the Death of Jermaine Baker, paragraph 13.77. ↩

3. The Jermaine Baker Public Inquiry: Report into the Death of Jermaine Baker, paragraph 13.81. ↩

4. Lord Wilson agreed with Lady Arden JSC and Lord Carnwarth delivered a short concurring judgment. Lord Reed PSC and Lord Kerr of Tonaghmore dissented. ↩

5. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 88. ↩

6. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 96. ↩

7. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 113. ↩

8. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 116. ↩

9. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 140. ↩

10. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 141. ↩

11. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 134. ↩

12. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 115. ↩

13. Taylor (2005) The Review of Police Disciplinary Arrangements: Report, recommendation 2 (iii) & 2 (iv). ↩

14. Submissions from the National Police Chiefs’ Council, 1.1. ↩

15. Submissions from the National Police Chiefs’ Council, 1.3. ↩

16. The IOPC submission to the Home Office’s Review of Investigatory Arrangements which follow police use of force and police driving related incidents, paragraph 20. ↩

17. The IOPC submission to the Home Office’s Review of Investigatory Arrangements which follow police use of force and police driving related incidents, paragraph 29. ↩

18. The IOPC submission to the Home Office’s Review of Investigatory Arrangements which follow police use of force and police driving related incidents, paragraph 31. ↩

19. The IOPC submission to the Home Office’s Review of Investigatory Arrangements which follow police use of force and police driving related incidents, paragraph 31. ↩

20. The IOPC submission to the Home Office’s Review of Investigatory Arrangements which follow police use of force and police driving related incidents, paragraph 45. ↩

21. The Inquest and Inquest Lawyers’ Group response to the Home Office’s Review of Investigatory Arrangements which follow police use of force and police driving incidents, paragraph 17. ↩

22. The Inquest and Inquest Lawyers’ Group response to the Home Office’s Review of Investigatory Arrangements which follow police use of force and police driving incidents, paragraph 20. ↩

23. Tim Owen KC et al (27 January 2023) Written Case for The Independent Office for Police Conduct, 6.b. ↩

24. Adam Straw (3 February 2020) Inquest’s Written Case, 2.b. ↩

25. Adam Straw and Jesse Nicholls (17 February 2023) Submissions by Inquest and Stopwatch, 2a, 2.c &31. ↩

26. Leading Counsel’s speaking note, Maughan. ↩

27. (14 January 2020) Statement of Case of the Appellant, Maughan, 4. ↩

28. The Baroness Casey Review (2023), page 190. ↩

29. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 126. ↩

30. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraphs 84 - 96. ↩

31. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 90. ↩

32. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 90. ↩

33. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 93. ↩

34. Coroners and Justice Act 2009, schedule 5, paragraph 7. ↩

35. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 90 & 134. ↩

36. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 138 and 139. ↩

37. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 138. ↩

38. See the Agreement Between the CPS, The National Police Chiefs’ Council, The Chief Coroner and The Coroners’ Society of England and Wales, 24 March 2016. ↩

39. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 107. ↩

40. R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent), paragraph 140 of the minority decision. ↩

41. R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents), paragraph 36 & 38. ↩

42. R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents), paragraph 38. ↩

43. R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents), judgments 45-52. ↩

44. Code of Ethics (July 2014), paragraph 4.4. ↩

45. Code of Practice for Ethical Policing (December 2023), paragraph 1.2. ↩

46. R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents), paragraph 94. ↩

47. R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents), paragraph 95. ↩

48. R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents), paragraph 96. ↩

49. R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents), paragraph 100. ↩

50. R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents), paragraph 97. ↩

51. R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents), paragraph 101. ↩

52. R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents), paragraph 103-104. ↩

53. Richard Martin (2021) When police kill in the line of duty: mistaken belief, professional misconduct and ethical duties after R(W80), page 7. ↩

54. Police (Conduct) Regulations 2020 (S.I. 2020/4), part 6. ↩

55. Police misconduct, England and Wales: year ending 31 March 2024, Chapter 4.8, table 4.7 & 4.8. ↩

56. R (on the application of Officer W80) (Appellant) v Director General of the Independent Office for Police Conduct and others (Respondents), paragraph 100. ↩

57. CASE OF McCANN AND OTHERS v. THE UNITED KINGDOM (1995), paragraph 200. ↩

58. CASE OF ARMANI DA SILVA V. THE UNITED KINGDOM (2016), paragraph 245. ↩

59. CASE OF ARMANI DA SILVA v. THE UNITED KINGDOM (2016), paragraph 248. ↩

60. Police Reform Act 2002, Section 12. ↩