The legal system is obsessed with a binary that doesn’t exist in human psychology. When a coroner rules they are "not satisfied" an individual intended to take their own life, they aren't uncovering a hidden truth about the victim’s soul. They are participating in a bureaucratic ritual designed to comfort the living at the expense of understanding the dead.
The case of Hatton—and dozens of similar high-profile inquests—highlights a glaring flaw in how we categorize self-inflicted death. We treat "intent" as a light switch. On or off. Yes or no. If there isn't a notarized letter or a Google search history for "final arrangements," the court flinches. It retreats into the safety of an "open conclusion" or "misadventure."
This is a failure of forensic logic. It ignores the reality of the "cry for help" that goes wrong and the cognitive fog of a mental health crisis where intent is not a fixed destination, but a flickering signal.
The Burden of Beyond Reasonable Doubt
In many jurisdictions, the standard for a suicide verdict was historically "beyond reasonable doubt." While that has shifted toward the "balance of probabilities" in some regions, the cultural hangover of the higher burden remains. Coroners are terrified of getting it wrong because of the perceived stigma attached to the word.
But here is the reality: waiting for 100% certainty in a situation involving a brain in total collapse is a fool's errand.
I’ve sat through enough data sets on mortality to tell you that the absence of a note means almost nothing. In fact, research suggests only about 25% to 30% of people leave a suicide note. Yet, the legal system treats the absence of one as a massive vacuum of evidence. We are applying 18th-century logic to 21st-century neurobiology.
The Fallacy of the Impulsive Act
The "lazy consensus" in media reporting on these cases is that if someone was making plans for the following week, they couldn't have intended to die.
This is dangerously naive.
The human mind is capable of incredible compartmentalization. You can buy a ticket for a concert on Tuesday and still decide life is unplayable on Wednesday. To a coroner, that ticket is "evidence of future intent." To a psychiatrist, it’s just a Tuesday.
By prioritizing "future plans" as a disqualifier for suicide, we create a narrative that self-inflicted death is always a long-planned, rational exit. It rarely is. It is often a sudden, overwhelming surge of pain. When we refuse to call it what it is because the person "seemed fine at lunch," we are lying to ourselves about how mental illness actually functions.
The Hidden Cost of "Open" Conclusions
We think we are being kind by avoiding the S-word. We think we are protecting a family’s legacy or a person’s reputation.
We are doing the opposite.
When a coroner returns an inconclusive verdict on a clear act of self-harm, they are muddying the waters for public health data. They are obscuring the true scale of the crisis. If we can’t accurately count the bodies, we can’t accurately allocate the resources to stop the next one.
- Statistical Erasure: Every "open conclusion" that should have been a suicide verdict is a data point lost to the void.
- Funding Gaps: Government budgets follow the numbers. If the numbers are artificially suppressed by hesitant coroners, the funding for prevention disappears.
- Family Limbo: While some families find relief in an open verdict, many are left in a state of "ambiguous loss," unable to fully process the reality because the state has officially told them it's a mystery.
Stop Looking for a Smoking Gun
The legal threshold for "intent" needs a total overhaul. We need to move away from looking for a "smoking gun" and start looking at the "trajectory of the bullet."
If someone takes a lethal action with a high probability of death, the legal system should stop trying to psychoanalyze the split second before the act. We cannot know what was in Hatton’s mind. We can, however, see the result.
Instead of asking, "Did they want to die?" we should be asking, "Did they knowingly engage in an act that any reasonable person knows causes death?"
The current system asks the court to be a mind reader. It’s an impossible task. It leads to inconsistent rulings where one coroner in London sees a tragedy, and another in Manchester sees an accident, based on the exact same set of facts.
The Professional Cowardice of the Inquest
I have seen the internal mechanisms of these investigations. There is a palpable pressure to avoid the "stigma" of suicide. This is professional cowardice masquerading as compassion.
If we want to actually honor the dead, we should be honest about the circumstances of their departure. Pretending a tragedy was a "misadventure" doesn't bring anyone back. It just makes the living feel slightly less uncomfortable for a few months while the underlying issues—isolation, lack of mental health infrastructure, and the lethality of certain methods—remain unaddressed.
We don't need more "satisfied" coroners. We need a legal framework that recognizes that human intent is messy, impulsive, and often contradictory.
Stop looking for the note that isn't there. Start looking at the reality of the act.
Demand that the legal system stops prioritizing "reputational management" over clinical accuracy.
The next time you read a headline where a coroner says they aren't "satisfied" regarding intent, understand that they aren't talking about the truth. They are talking about a lack of paperwork.
Accept that the absence of proof is not the proof of absence.
Stop sanitizing self-destruction.
