For those who find themselves involved in an inquest, we have provided a summary of matters which may be of relevance. If you would like any further information, please do not hesitate to contact one of our inquest specialists.

An inquest is a fact-finding exercise conducted by a coroner, in some cases in front of a jury. Under the legislation relating to inquests, the role of an inquest is to determine who died, as well as when, where and how the death came about. It is not the purpose of an inquest to attribute blame or legal responsibility for the death but where it is necessary in order to avoid a breach of a person’s rights under the Human Rights Act 1998, the coroner must ascertain the circumstances in which the deceased came by their death.

A potential breach of a person’s human rights will not have occurred in every instance where a person has died and where an inquest is potentially to be held and indeed this will only be the case in limited circumstances. However, it could potentially apply where there is an argument that the deceased’s ‘right to life’ was breached whilst they were in state detention, e.g. whilst they were a prisoner or were receiving inpatient treatment for mental health issues.

The coroner will be a qualified doctor or lawyer (or both) and will have been appointed by the local authority to investigate deaths occurring in his or her district where certain criteria are met (see ‘Why is an inquest held in some cases and not others’ section below). It is the coroner’s job to try to answer the questions referred to above.

The coroner’s officer is often a former police officer and their job is to assist the coroner in preparing for an inquest, e.g. by obtaining witness statements or reports from people who were involved in the circumstances leading up to the death, and possibly from independent medical experts. The coroner’s officer will usually be the person liaising with the family of the deceased regarding the inquest, as well as anyone else who is considered to have an interest in this.

Certain people are entitled to be provided with information in relation to an inquest and to ask questions of any witnesses giving evidence at this. These ‘interested persons’ include:

  • the deceased’s spouse, civil partner, parents, children, siblings, grandparents, nieces and nephews, stepparents or half-siblings
  • the deceased’s personal representative (such as the executor of their will)
  • any other person the coroner thinks has sufficient interest

Coroners are notified of deaths within their district but they are only obliged to investigate the death where:

1. the death was violent or unnatural

2. the cause of death is unknown

3. the death occurred in custody or when they were otherwise in state detention (e.g. whilst the person was detained under the Mental Health Act 1983)

Where a coroner is obliged to investigate a death, a post mortem examination will usually be ordered. If so, the coroner must notify the deceased’s next of kin or personal representative (and any other interested person who has notified the coroner in advance of their wish to be represented at the post mortem) of the date, time and place at which this will be carried out. However, the coroner need not provide this notification if it is impracticable to do so or if this would cause the post mortem to be unreasonably delayed.

The next of kin or personal representative (and other interested persons who have given advance notification to the coroner of their wish to do so) are entitled to be represented at the post mortem by a medical practitioner. If they are themselves a medical practitioner then they can attend the post mortem, if they so wish.

If any material is taken and retained from the post mortem, e.g. tissue samples, the coroner must notify the next of kin or personal representative that this has been done, as well as of the reason why and what the options for dealing with the material once this is no longer required. The options include burial or cremation of the material, or returning this to the next of kin or personal representative.

The coroner must release the deceased’s body for burial or cremation as soon as this is reasonably practicable. If they cannot do so within 28 days of being made aware of the death, they must notify the next of kin or personal representative of the reason for the delay.

If the post mortem reveals the cause of death and the coroner thinks it is unnecessary to continue the investigation then an inquest will not be held, unless the coroner has reason to suspect the cause of death was violent or unnatural, or the deceased died in state detention.

If the coroner decides to discontinue an investigation into a death following the post mortem, they are obliged to give any interested person a written explanation as to why, if the interested person requests this in writing. If the coroner decides not to hold an inquest when it is arguable that they should have done, it may be possible to apply to the civil courts to request that one be held.

The coroner will set a date for the inquest and, ideally, will liaise (via the coroner’s officer) with any interested persons about their availability before doing so. Either way, the coroner must notify the deceased’s next of kin or personal representative, as well as any interested persons who have made themselves known to the coroner, of the date for the hearing within a week of fixing this. The inquest hearing must be held on a work day unless the coroner considers there is some urgent reason for holding it on some other day.

A coroner must complete an inquest within six months of the date on which they were made aware of the death; or as soon as reasonably practicable after that date. Unfortunately, due to many coroners’ courts being over-stretched and under-resourced, it is not unusual for an inquest hearing to take significantly longer to be concluded. However, if the investigation has not been completed or discontinued within a year of the date on which the death was reported, the coroner must notify the Chief Coroner of this and provide an explanation to them.

Any interested person is entitled to obtain a copy of the post mortem report, should they wish to see it. If the relatives of the deceased or someone accused of causing the death in a criminal case are dissatisfied with the results of the post mortem, they can ask the coroner for permission to arrange a second post mortem themselves. However, this would be performed at their own expense, rather than the authorities’.

There may be other documents which interested persons would want to see, such as copies of any witness statements or medical experts’ reports which the coroner has obtained. Where an interested person asks the coroner for copies of documents held by the coroner, the coroner must provide these or make them available for inspection as soon as is reasonably practicable, unless:

1. there is a statutory or legal prohibition on disclosure

2. the consent of any author or copyright owner of the document cannot be obtained

3. the request is unreasonable

4. the document relates to contemplated or commenced criminal proceedings

5. the coroner considers the document irrelevant to the investigation

The coroner cannot charge an interested person for providing them with copies of any documents prior to or during an inquest. However, the coroner can make a charge when disclosing documents to interested persons after an inquest.

An inquest will be held in public (and so members of the public and the press will be entitled to attend), unless the coroner considers that it would be in the interests of national security to exclude the public from part or all of the hearing.

At the hearing, the coroner must allow any interested person or their legal representative to put questions to the witnesses, if this has been requested. The coroner will put their questions to the witnesses first, followed by the interested person (or their lawyer) and finally the witness’s own legal representative (if they have one).

The coroner must disallow any questions which they consider irrelevant, e.g. if they think the question falls outside the scope of what they are obliged or allowed to cover during the hearing. Furthermore, no witness is obliged to answer any question that may incriminate them in any criminal proceedings.

Some of the people from whom the coroner has obtained evidence prior to the hearing may not be called to give evidence in person. Instead, the coroner may put their written statement or report into evidence at the hearing, but only if:

1. it is impossible for the person who made the statement or report to attend the hearing at all, or to do so within a reasonable timeframe

2. there is a good and sufficient reason why they shouldn’t attend

3. there is good and sufficient reason to believe they will not in fact attend

4. the written evidence is unlikely to be disputed

Any interested person can object to written evidence being admitted and they are entitled to see it before this is done.

The coroner will complete a document called the ‘Record of an inquest’, which includes the name of the deceased, the medical cause of death, how, when and where (and possibly in what circumstances) the person died and the coroner’s conclusion or ‘determination’ as to the death. There are various short-form determinations (sometimes referred to as ‘verdicts’, though this is not the technical legal term) which a coroner might reach, such as:

1. accident/misadventure

2. alcohol/drug-related

3. industrial disease

4. lawful/unlawful killing

5. natural causes

6. road traffic collision

7. stillbirth

8. suicide

If there is, in the coroner’s view, insufficient evidence to prove another verdict, they can record an ‘open’ verdict. Alternatively, if the coroner doesn’t wish to use one of the above then they can give a ‘narrative’ conclusion, summarising the relevant events leading to someone’s death.

If the coroner is concerned that there are circumstances which give rise to the risk of other deaths occurring and they believe action should be taken to prevent or reduce this risk, they must report the matter to a person who may have power to take such action. Where the coroner makes such a report the recipient must give a written response. Copies of both the report and the response must be sent to the Chief Coroner and the coroner may also send a copy to any interested person they believe should see it.