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What is an inquest?

An inquest is a public judicial inquiry presided over by one of Her Majesty’s coroners’ to investigate a set of facts concerning a person’s death. 

Each geographical area has a coroner who is notified upon any death and if s/he is satisfied as to the cause then they will issue a death certificate. However, if deaths are of an unnatural, violent or unexplained nature, or where the deceased was in the care or custody of the state at the time, then the coroner has a duty to open an investigation or a full inquest. Inquests are usually held in a courtroom and are open to the public including members of the press who can report on proceedings unless the coroner directs otherwise.

The coroner’s role is limited to answering who the deceased was, the medical cause of their death, when and where it happened and how they came about their death. They cannot frame their findings in a way as to appear to determine any question of civil or criminal liability, with the exception in some cases of neglect.

The coroner has a duty to suspend an inquest a) if they are asked to do so by the Crown Prosecution Service because someone may be charged with a homicide or related offence, b) if third party involvement is suspected, at which point the matter will be referred back to the police or CPS or c) where there is a public inquiry or investigation by, for example, the Health and Safety Executive. It is common in cases where there are active proceedings such as a criminal investigation or public inquiry that the inquest will be opened and adjourned until these have concluded.

Coroners are permitted to hold inquests by simply reading agreed reports into evidence if there is nothing to gain from calling the witnesses to give evidence in person. There are called ‘Rule 23’ inquests. In the alternative, witnesses may be called to provide oral evidence and to enable them to be cross-examined in addition to receiving the usual written statement and/or reports. As with criminal courts, a failure by witnesses to respond or appear may result in them being held in contempt of court.

Commonly witnesses will include the deceased’s next of kin or a close family member, any witnesses to the death, their GP and any other medical professionals or emergency services staff who may have responded or treated them prior to death. The pathologist who carried out the post-mortem will usually submit or be called to read their report and potentially other experts in relevant fields.

In more complex cases the coroner may hold a series of pre-inquest review hearings which is an opportunity for written and oral submissions to be made to establish key issues such as who the interested persons are, the scope of the inquest, which witnesses should be called and expert evidence obtained. This is the best opportunity for the deceased’s family or their lawyer to raise any concerns they may have.

Who is the coroner?

Coroners are independent judicial officers who are appointed by the local authority and must have a legal background and at least five years’ experience in the field. Historically, coroners could also be medical practitioners with no legal background but this changed as a result of the Coroners and Justice Act 2009, a potential reason being that they may be biased towards medical evidence rather than being able to independently assess what is put before them.

What findings can the coroner make?

There are a range of short-form conclusions a coroner can reach at the end of an inquest which, with the exception of suicide, are decided on the ‘balance of probabilities.’ These are:

  • Natural causes
  • Accidental death
  • Misadventure
  • Alcohol/drug-related
  • Industrial disease
  • Open
  • Road traffic collision
  • Stillbirth
  • Suicide
  • Lawful killing
  • Unlawful killing

The coroner may also return a narrative conclusion either instead of, or in addition to, a short-form conclusion, which sets out the circumstances of the death in more detail. The recording of an open conclusion occurs when it is deemed that there is not enough evidence to reach a decision, although this is discouraged and so rarely occurs.

Coroners have a duty to report where there appears a significant risk of future deaths occurring in similar circumstances. These are known as ‘Preventing Future Death’ reports or a ‘Regulation 28 report’ and those who are in a position to enact change as requested in such reports have 56 days to evidence what action they propose to take.

Different types of inquest

In certain circumstances an inquest may be heard by a jury as well as a coroner. These include where the death occurs in prison, police custody, while the deceased was detained under the Mental Health Act or Mental Capacity Act or died as a result of an accident at work. The coroner may also direct that a jury is called in cases where there is a significant public interest in doing so.

Where a person has died while in the care or custody of the state, an inquest may engage ‘Article 2’ in accordance with Article 2 of the European Convention on Human Rights. This means the scope of the inquest is wider and likely to be more thorough as there is an investigative obligation on the coroner and the state to look more widely at the circumstances in which the deceased died.

In special circumstances, a coroner may be appointed from outside the area. A recent example is the inquest into the Manchester arena terror attack which one of the country’s most senior judges, Sir John Saunders, has been appointed to oversee due to the sensitive nature of the evidence and the relevant experience and security clearance required.

Do I need legal representation?

This decision is down to the individual and depends upon the circumstances of the death and issues and concerns of the families. Anyone with a stakehold in the inquest can apply to be an ‘interested party’ and as such has the right to ask questions of any witnesses and to seek disclosure of the evidence ahead of the hearing. As an interested party, you are also entitled to request copies of the coroner’s findings and any recommendations.

Given the complexities of some cases, legal representation can be beneficial for those who have serious concerns about their loved one’s death. Organisations such as the police, NHS and local authorities who are called to give evidence at inquests are commonly represented by their own legal team. It is worth checking whether your case qualifies for legal aid, although funding cuts in this area mean it is not as readily available as it once was.

Can I challenge the coroner’s verdict?

Broadly speaking there are two avenues that can be pursued post-inquest if interested parties are dissatisfied. The first is judicial review if, for example, there has been an error of law as the inquest could be re-opened or re-heard if there is a qualifying reason to do so. If this is something you are considering you should seek independent legal advice as quickly as possible to establish if you have grounds to do so.

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