The inquest held in April 2003—approximately thirteen months after Darwin’s disappearance—returned an open verdict. An open verdict means the coroner was unable to determine from available evidence the cause of death. In cases of disappearance at sea without a body, this is the standard outcome: there is sufficient evidence to presume the person is dead (the disappearance, the damaged craft, the failed search), but insufficient evidence to establish the precise mechanism of death.
The open verdict was entirely appropriate given what the inquest could know. The coroner had access to the police records of the search, the report on the damaged canoe, testimony from those who had known Darwin and who confirmed he had gone out that morning, and Anne’s account. None of this evidence, taken at face value, suggested anything other than an accident at sea.
What the coroner could not know—what no one who believed Darwin was dead could know—was that the man was alive and had manufactured the evidence they were examining. The inquest is another example of the same pattern: an institution responding appropriately to the information available to it, producing an outcome that was reasonable given that information, and being deceived because the information itself was false.
After an inquest has returned an open verdict and a death certificate has been issued, opening an inquiry into whether the deceased is actually alive requires a specific trigger. The institutions that had paid out benefits and pensions were not, in the ordinary course of their operations, going to revisit a paid claim from 2002 without external prompt. The colleague’s phone call in September 2007 provided that prompt. The five-year gap between the inquest and the beginning of the formal investigation is not evidence of institutional failure; it is evidence of the difficulty of identifying fraud that is supported by apparently legitimate documentation.