Coroners Inquests

In most cases, a GP or hospital doctor can issue a medical certificate stating the cause of death and the registrar will then issue a death certificate. If death was unexpected or suspicious or if doctors are uncertain about the actual cause, the coroner is likely to be involved and an inquest may be held.

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The coroner is an independent judicial officer whose role is to investigate any death in his/her jurisdiction reported to him/her which is violent or unnatural or the cause is unknown or which occurs in prison, police custody or other state detention for example a patient detained under section 2 of the Mental Health Act. The coroner is required by law to establish, if possible, the medical cause of death and to answer 4 questions, namely, who died, where and when they died and how they came by their death.

The Coroner's job is to gather information to determine if a medical certificate of cause of death can be issued or if further investigations are required. If the certificate can't be issued, the coroner will order a post-mortem examination.

If the Coroner is satisfied that the post-mortem examination shows that the death was due to natural causes and an inquest is not needed, the Coroner will release the body, the death can be registered as normal and the funeral can take place.

There are certain cases when an inquest must be held,even if death is from natural causes, for example if the death was in custody but otherwise an inquest usually follows a sudden or unexpected death in unexplained circumstances.

The purpose of the Inquest is to enable the Coroner to determine who died, when they died, where they died and how they came by their death. The Coroner cannot apportion blame. It is an inquisitorial process involving an investigation followed by a hearing where evidence will be given under oath. The deceased's family has the right to participate in the proceedings and to ask questions of the witnesses.

If death occurred in hospital or a nursing home the inquest may be the only time that doctors, nurses or carers will ever fully explain what they did and describe exactly what happened.

Listening to details of how death occurred and what was discovered at the post-mortem can be a harrowing experience for relatives. Having legal representation at an inquest means there is someone who can give you informed and objective advice to help guide you through the process and explain what's happening.

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How long will an inquest take

Whatever the circumstances surrounding any death, the inquest is an early (and often the only) opportunity for relatives to hear what happened. How long it may take to get those answers has been difficult to predict.

The coronial service is under tremendous pressure and bereaved relatives in some parts of the country have had to wait years for an inquest to even begin.

New rules for coroners throughout England and Wales took effect from 25th July 2013. Now the Chief Coroner for England and Wales oversees coroner services to ensure adherence to the new national code of standards designed to lead to a more efficient system of investigations and inquests.

Coroners must complete inquests within six months of being informed of a death or 'as soon as is reasonably practicable after that date'. This may take some time to implement as some parts of the country have rather longer waits than others. Any inquests that are not concluded within a year must be reported to the Chief Coroner with reasons for the delay.

The purpose of an inquest is not to determine blame it is to address the 4 questions of who died, where and when they died and how they came by their death. The conclusion, (previously called the verdict) will not identify someone as having criminal or civil liability. If there is criminal investigation into the death, the inquest will be adjourned pending the outcome of that investigation. If that investigation establishes the cause of death there will be no requirement for the inquest to be resumed.

More about coroner’s inquests

An inquest may provide some of the answers you seek and the information revealed may also be very helpful to a possible claim. In Scotland a ‘fatal accident inquiry' is held and although it has the same purpose as an inquest, when it is convened and how it is arranged is significantly different to English law.

An inquest is usually opened to record the death and issue documents required for burial or cremation. It’s then adjourned until any police enquiries or coroner's investigations are completed. The full inquest can then be resumed, so it's not unusual for the inquest to take place sometime after the funeral.

The coroner's role is not to apportion blame for the death. The coroner does however have the power to investigate not just the main cause of death, but also anything which directly lead or contributed to it. All inquests must be held in public and the press can be present. Most inquests are held without a jury except for certain types of death e.g. a death in prison. Witnesses called to give oral evidence at inquest are required to do so under oath.

The coroner is limited in the range of conclusions (previously called verdicts) that can be given. These include: natural causes, industrial disease, want of attention at birth, suicide, accident or misadventure, lawful or unlawful killing or still birth.

An open conclusion is reached when there is insufficient evidence for any other conclusion. More recently narrative conclusions, which set out a brief summary of what happened, have become more common.

Representation at inquest

Sometimes there may not be an inquest despite the fact that you feel an official investigation is needed. Sometimes after a post-mortem examination (autopsy), the coroner will be able to establish that the death is from natural causes and there may therefore be no need for an inquest.

The immediate family of the deceased is entitled to participate in the inquest and ask questions of the witnesses. However, we appreciate that this is a very difficult and distressing time for the family. 

Having legal representation at an inquest means there is someone who can sit beside you and help guide you through the process, explain what is happening and to raise any questions you have with the witnesses. If you are considering a possible compensation claim, having legal representation at the inquest is extremely valuable.

Although the inquest will not address the issue of who was to blame for the death, your solicitor can at least ask questions and obtain information which could be helpful to your claim.

Having a legal professional alongside you can also help with challenging procedural decisions made by a coroner and can assist if you wish to overturn a conclusion and obtain a fresh inquest hearing because of inadequate inquiry by the coroner.

Access Legal can give you clear, uncomplicated options for a solicitor or a barrister to represent you and your family's interests at an inquest, guiding you through the procedure and reassuring you that the right questions are being asked.

The role of the coroner

The coroner is an independent judicial officer whose role is to investigate any death in his/her jurisdiction reported to him/her which is violent or unnatural or the cause is unknown or which occurs in prison, police custody or other state detention, for example, a patient detained under section 2 of the Mental Health Act. Since 2013 newly appointed coroners must have 5 years of legal practice or part-time judicial practice. Coroners who were in post before 2013 could be lawyers or doctors.

The coroner is required by law to establish, if possible, the medical cause of death and to answer 4 questions, namely, who died, where and when they died and how they came by their death.

The coroner as part of his investigation may instruct a pathologist to carry out a post mortem examination (autopsy). If the autopsy confirms that the death occurred from natural causes there may be no need for further investigation. The coroner will release the body, the death can be registered as normal and the funeral can take place. If there is uncertainty as to the cause, the coroner will hold an inquest.

An inquest is a public hearing held in the Coroner’s Court and the coroner or a jury will listen to evidence to establish the answers to the 4 questions.

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Coroners Inquests

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