For healthcare organisations, a finding of neglect remains one of the most serious parts of a conclusion that can emerge from an inquest. Although such findings are relatively rare, the publication of the Chief Coroner's 2025 Bench Guidance (“the Bench Guidance”) provides the clearest and most comprehensive statement to date of the principles coroners should apply when considering neglect.
Why is the Bench Guidance useful?
The Bench Guidance consolidates previous guidance notes, authorities on neglect findings and case law into a single resource and can act as vital, initial guidance for healthcare organisations when navigating coronial investigation.
What does "neglect" mean in an inquest?
In the coronial context, neglect has a specific legal meaning. It is not indicative of poor care, negligence, suboptimal treatment, a mistake, or even serious professional failings. Instead, the test requires:
a gross failure to provide basic care or basic medical attention
the deceased to have been in a dependent position, relying on others for that care
a clear, causal connection, or material contribution, between the failure and the death
It is important to note that clinical negligence, gross negligence and coronial neglect are not the same thing. They are distinct legal concepts from different forums. A finding of one does not require, establish or automatically lead to the other. Clinical negligence concerns whether a duty of care was breached causing harm, whereas a coroner's finding of neglect is a factual conclusion about a gross failure to provide basic care in circumstances relevant to the death.
Why are “Neglect” findings rare?
Recent commentary from coroners and practitioners continues to emphasise that, due to the narrow test establishing a high threshold and restricted meaning, neglect findings are exceptional. For healthcare providers, this is an important reminder that:
not every care failure will justify a neglect conclusion
coroners will examine whether the failure involved a gross absence of basic care
the issue is often one of systemic or fundamental omission rather than imperfect clinical judgment
Real examples of when the “neglect” threshold has been met
In March 2026, an inquest into the death of Irene Dzifa King Arthur concluded that there had been gross failures in hospital care amounting to neglect. The coroner identified missed opportunities to investigate worsening symptoms, failures to recognise the need for blood transfusion and failures to respond appropriately to escalating clinical indicators, all of which materially contributed to death. What makes this useful is that the coroner reportedly went further than merely identifying clinical mistakes. She described a "significant lapse in care", a lack of "clinical curiosity", and "gross failings" which could have prevented the death if the appropriate intervention had been provided.
In August 2026, in the inquest of Julie Ley, a mental health patient, the coroner found neglect where:
nutrition was not monitored appropriately
insufficient action was taken when the patient stopped eating and drinking
the patient was not transferred to a suitable hospital capable of providing treatment
statutory powers available under the Mental Health Act were not used
physical deterioration was not properly monitored
Most importantly, the NHS trust reportedly accepted that she would not have died but for these failures. That is very close to the classic Jamieson concept of neglect: failure to meet fundamental needs of a dependent person.
How can healthcare organisations prepare for inquests in light of possible “neglect” findings?
identify early whether neglect is likely to be a live issue, particularly where there are concerns about nutrition, hydration, basic nursing care, observations, medication administration, escalation of deterioration or access to urgent medical treatment
secure and review the contemporaneous evidence, including observation charts, nursing records, fluid and nutrition charts, escalation records, care plans and incident reports
assess the chronology carefully, as neglect findings often arise from persistent omissions or failures to act in the face of obvious deterioration rather than a single clinical error
address both actions and omissions in witness evidence, ensuring clinicians and staff explain not only what was done but why certain steps were not taken
demonstrate the organisation's response, including internal investigations, learning, policy changes and patient safety improvements made following the death
obtain early legal advice where a finding of neglect is a realistic possibility, as this may affect the scope of the evidence, witness preparation and submissions to the coroner
Conclusion
The 2025 Chief Coroner's Bench Guidance does not alter the law on neglect but provides the clearest and most accessible summary of the applicable principles to date. For healthcare providers, the message is reassuring but important: neglect remains a serious and relatively rare finding reserved for gross failures to provide basic care that contribute to death. At the same time, recent cases demonstrate that where fundamental care needs are unmet, coroners remain willing to make such findings. Understanding the distinction between clinical error and coronial neglect, preparing early, and evidencing robust governance and learning will remain crucial in managing risk and responding effectively at inquest.
For more information, please contact our expert health and care solicitors.
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