Coroner's Inquests

An inquest is a legal procedure held by a Coroner to investigate deaths that are sudden and appear accidental or suspicious. 

Coroners work within set geographical areas, over which they have jurisdiction. The Coroner’s duty is to establish who has died, the time and place of death, and a cause of death (a sudden death is more likely to come within the Coroner’s remit). Accordingly, if one or more of these factors is unclear, the death in question has to be reported to the area Coroner. The Coroner will also have to ascertain that the body of the deceased person lies within the area over which he or she has jurisdiction before an investigation can commence (death can have been caused elsewhere). Assuming that there are felt to be questions to be answered and the body lies within his or her jurisdiction, the Coroner may then decide to hold an Inquest. The function of the Inquest is to clear up questions the death raises within the parameters detailed above. It is important to realise that Coroners are only required to establish a general cause of death.

Of deaths that are reported to the Coroner, only about 10 – 13% lead to an Inquest. (Full government statistics of deaths dealt with within Coroners’ Offices in England and Wales can be found at statistics/cb2006full3.pdf)

In cases involving stillbirth, the Coroner may decide to investigate if it is unclear as to whether the child was in fact alive at the point of delivery.

In addition to enquiring into the circumstances of certain deaths, Coroners have the power to investigate finds of treasure in their districts, and to establish who the finders were (see the Treasure Act 1996, effective from 24 September 1997). Such enquiries are also referred to as inquests, but are rather unusual.

What happens during an Inquest?

An Inquest is a Public Hearing. Members of the immediate family of the deceased should therefore be informed by the Coroner if an Inquest is felt to be required, so that they can attend if they wish. Inquests are usually formally opened quite rapidly after death and/or a post mortem examination. In practice, though, this does not mean that the matter will be fully investigated immediately. In fact, in most inquests, proceedings are adjourned after the initial hearing. The reason for this delay is so that the Coroner can prepare the groundwork to the Hearing, in the first instance by making enquiries into the circumstances of the death.

Following this process of initial enquiry, a list of witnesses to be called is drawn up, and a further investigation, together with written evidence, is organised. This latter evidence garnered can take a number of forms:

  1. Statements should be gathered from anyone who has relevant information to give (n.b., if a government organisation such as the Police is involved, it may be that statements and other investigations already undertaken by that body will simply be passed on to the Coroner);
  2. Expert witnesses – usually but not necessarily clinicians – may be called upon to examine either or both the body (whether in its entirety or tissue samples), and the written evidence adduced. They may then be asked to prepare formal reports based upon their findings;
  3. Any internal enquiries from organisations involved should be passed to the Coroner for subsequent review, and as a basis for investigation. This type of evidence can be particularly important in the case of deaths involving a state organisation – e.g., deaths in police custody, deaths in prison, and deaths involving mental health service providers.

Once all the investigations deemed necessary have been finalised, the Coroner will set a date for the Inquest. It is not uncommon for this date to be some months in the future, and there are normally logistical reasons for this. The Coroner’s Officer(s) responsible for the administration of the Inquest has to make sure that all the witnesses called can attend within a short timeframe (typically, anywhere between a day and two weeks): expert witnesses in particular tend to be incredibly busy, and getting their diaries to coincide is often something of an art form. The Coroner will also have to liaise with any legal representatives retained by the interested parties, and this can occasionally cause difficulties, as when there is debate as to the scope of the enquiry.

If the death under investigation is already the subject of criminal proceedings, and/or the circumstances or events surrounding the death are to be investigated in a Public Inquiry, the Inquest cannot proceed until those investigations have been completed. The Coroner must then form a judgement as to whether the Inquest should proceed any further: if all the issues that he or she has to investigate have been dealt with already, then the Inquest will be formally closed.

Can families participate in Inquest preparation?

The answer to this is, "tentatively, yes". If you are a close relative of the deceased (e.g., parent, child, spouse), then you are deemed to be a "properly interested party". Other friends and relatives might be considered, depending upon the circumstances. Close relatives should ordinarily be able to participate in the Inquest itself, and usually also its preparation. You should be aware that similar rights are likely to be extended to any person and/or organisation who is implicated in the death – e.g., if a death occurred in prison or police custody, it would be common for either HM Prison Service or the local Constabulary to have some input into the Inquest’s preparation.

While there are no formal guidelines concerning the way in which an Inquest should be prepared for, Coroners frequently facilitate disclosure of relevant paperwork to bereaved families. Recommendation No.42 of the Stephen Lawrence Inquiry states that "… there should be advance disclosure of evidence and documents as of right to parties who have leave from a coroner to appear at an inquest." The evidence and documents to be disclosed may include such items as the deceased’s medical records (and, if applicable, custodial records), post-mortem report and statements.

Assuming you or your legal representatives obtain disclosure of the records to be considered by the Coroner, there is nothing to stop you from drawing up a list of questions which you feel are raised.

It may well be of assistance to the Coroner for you to discuss matters of concern regarding the death of a family member. Some Coroners hold pre-Inquest hearings at which the scope of the Inquest can be discussed: if one of these is organised, you can attend in person (with or without a legal representative) or ask a legal representative to attend on your behalf. The Coroner may well ask what sort of involvement you are likely to want in the proceedings, and may wish to discuss the proceedings with you in the light of that. It is important to remember that the Coroner may not be empowered to take things as far as you would like: his or her function is to find a general cause of death, rather than to apportion blame.

The Inquest: Procedure

Inquests have to take place in public – indeed, until the mid-nineteenth century it was a requirement for Coroners’ Inquests not only to be held in public, but specifically in public houses (the most famous literary example of this modus operandi is to be found in Dickens’ 1853 novel, Bleak House). Whilst it would be rare for the public to turn out in force, you should be aware that the press may very well be in attendance. Some families find media interest quite intrusive, but in reality there is little that the Coroner can do about this.

The Coroner oversees the proceedings rather like a judge. In some cases, a jury will be present. The legal representatives of the interested parties will be present, as will the witnesses called to give evidence. There will generally be separate seating arrangements for the legal representatives, and the public will be seated further back.

A list of witnesses will by this time have been drawn up. They may be asked about some or all of the documentation that the Coroner has decided to admit as evidence. They may simply be asked to give an account of the relevant events.

All witnesses who are called to appear will first be asked questions by the Coroner, and may thereafter be questioned by the interested parties (or, more usually, their legal representatives). If you are called to give evidence, you will certainly be questioned by the Coroner – it is up to the other parties there as to whether or not they question you. If you have one, your own legal representative will question you last.

The questions that can be put in Inquests are in practice limited by the legal provision that no witness is obliged to answer a question that might incriminate himself. Coroners certainly ought to be well aware of this requirement, and it would be extremely surprising if a Coroner either put a question that might incriminate a witness or for that matter allow any party’s legal representative to do so without intervening. If the Coroner felt that witnesses were in danger of incriminating themselves by answering a question, he or she would be expected to make them aware that they do not have to answer.

The Inquest: The Verdict

The verdict of a Coroner’s Court constitutes its finding as to the nature of the death which it has been convened to examine. In practice, the verdicts are generic in nature – that is to say, almost invariably, the death under investigation will be placed within one of the following set categories:

  • Accident/misadventure (n.b., although these are bracketed together, they are separate verdicts)
  • Natural causes
  • Open verdict
  • Narrative verdict
  • Dependence on drugs/non-dependent abuse of drugs
  • Aggravated by Self-Neglect/Neglect
  • Suicide
  • Lawful killing
  • Unlawful killing
  • Industrial disease

The verdict may well be the point in an Inquest that the family of the deceased finds hardest to cope with. This is because Coroners are not allowed to apportion blame, and not infrequently, families firmly believe that someone is at fault.

The nearest a Coroner is likely to come to addressing the concerns of a family of someone who has died whilst in the care of an organisation (whether a care home, a hospital, a police station or a prison) is a narrative verdict. "Narrative verdicts" indicate that death took place for a series of reasons, and, whilst they do not of themselves apportion blame, these verdicts can frame the circumstances of the death in a very unflattering light, so far as the deceased’s carers are concerned. The Coroner may also make recommendations with regard to the institutions involved based upon the findings. Whilst this does not apportion blame as such, it is readily apparent that no Coroner would make such recommendations if serious flaws in the deceased’s treatment had not been found.

The Coroner may go so far as to state that the death was "aggravated by a lack of care" (this is known as a verdict of "neglect"), but in practice, this is an exceptionally rare judgement, and can only be added to a limited number of verdicts. The faults in the care afforded would have to be glaringly obvious and shocking in order for most Coroners to reach such a verdict.

At the conclusion of the Inquest, the Coroner should make a copy of his or her verdict available to close relatives of the deceased’s immediate family. The Coroner may also disclose to the family documents produced in evidence and annotations based upon these. The Coroner should also submit a death certificate to the Registrar of Births and Deaths, detailing the time, place, and findings of the Inquest.

If you are dissatisfied with the way that an Inquest into the death of a close relative is being handled, do please get in touch. Our specialist team one of whom is an Assistant Deputy Coroner in what is often referred to as her "spare time") will be happy to help.

Legal representation at Inquests

Before you contemplate obtaining Legal Representation at an Inquest, you need to think how you might go about funding this.

It can be extremely difficult to obtain Public Funding ("Legal Aid") for families at inquests. Public Funding is only likely to be available for certain types of Inquest, particularly deaths in police custody or prison. Furthermore, Public Funding is not normally granted to one person within the family – rather, the means of all the interested members of the family are assessed, and consequently, anyone in the family who would not ordinarily qualify for Public Funding might risk paying a substantial contribution, even were such Funding to be granted.

It is unlikely that any firm of solicitors would be able to offer you a "No Win No Fee" package for representation at an Inquest, if only because nobody wins or loses in the Coroner’s Court – the Hearings are strictly non-confrontational, albeit that the interests of the parties present may well be divergent from one another.

If you have any insurance policies (e.g., home and contents insurance policy, credit cards), it would be worth checking these to assess whether you have the benefit of Legal Expenses Insurance. If you have such cover, you would need to check carefully with your insurer(s) to see whether they would agree to provide cover for representation at an Inquest. This is by no means certain.

If the Inquest involves an industrial accident and the deceased was a member of a Trade Union, it would definitely be worthwhile contacting the Union to ask if they would be prepared to cover the costs of legal representation at the Inquest – particularly if the circumstances of the death raise wider issues.

However, most families will be faced with the prospect of instructing a solicitor privately. While this could be enormously costly (particularly were you to have to pay for the services of a barrister), you do not necessarily need to be represented at the Inquest. If you are in this position and you wish to discuss your options, do please feel free to contact us.

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