What is an Inquest?
The Coroner
Post Mortem Examinations
Inquest Procedure
The Inquest Hearing
Adjourning an Inquest
The Scope of Inquests
Funding
Disclosure of evidence
Witnesses
Pre-Inquest Meetings
Verdicts
1. What is an Inquest?
An inquest is an investigation held by a Coroner to determine how, when and where an individual has died. The purpose of an inquest is to establish the facts and reach a verdict as to the cause of death.
The Coroner will usually hear the inquest himself, but in certain circumstances he will require a jury to hear the inquest and return a verdict, normally where: ‘the death occurred in circumstances the continuance or possible recurrence of which is prejudicial to the health or safety of the public..’
An inquest is held if the cause of a death is in doubt or if a death has occurred under any of the circumstances detailed below. In such cases the death is reported to the local Coroner, that is the Coroner who governs the jurisdiction where the death occurred or the airport to which the deceased has been repatriated. Approximately 1/3rd of all deaths in England are reported to the Coroner either by doctors, the police or registrars; around 12% of these reported deaths will result in inquests.
Deaths which require an Inquest to be opened due to:
- Violent or suspicious circumstances.
- An accident, including work related accidents.
- Industrial disease.
- Self harm, overdose or drug abuse.
- Poisoning.
- Neglect.
- Deaths in prison or police custody.
Certain medical/hospital deaths including:
- Death occurring during a surgical procedure or within 24 hours of such surgery.
- Death within 24 hours of hospital admission.
- When the deceased was detained under a section of the Mental Health Act 1983.
- When the attending doctor (i.e. GP) had not seen the deceased within 14 days before their death.
- Where the attending doctor considers he is unable to sign the Death Certificate, because the cause of death is unknown or there is concern/suspicion in relation to treatment given.
2. The Coroner
The office of the Coroner dates back to the 12th century. The Coroner is an independent judicial officer responsible only to the Crown. At present only the Lord Chief Justice can remove a Coroner from office. Unusually for a judicial office, the local authorities are responsible for appointing and funding the Coroner. However, other than appointing the Coroner, the local authority has no power, authority or influence over the Coroner.
The Coroner must have been qualified as a solicitor, barrister or medical practitioner for over five years. In practice experience of nearly 20 years is more likely and of those who are presently sitting as Coroners, there are very few now who do not have a legal qualification. In future Coroners will not be able to be appointed without a legal qualification .
The new Coroners and Justice Act 2009 will bring in many changes to the way in which Coroners are to be appointed and governed. Although this Act came into force in November 2009 the majority of its provisions are yet to be put in place pending lengthy consultation processes and drafting of further secondary legislation.
The main changes under this Act will be as follows:-
- Clear guidance on when ‘legal aid’ is available for representation at an inquest hearing;
- A new role of ‘Chief Coroner’ is created, who will be responsible for hearing appeals concerning Coroner’s decisions, maintaining national standards and providing leadership;
- Coroners will now be nominated by their local authority for approval by the Lord Chief Justice, Lord Chancellor and the Chief Coroner; this includes approval of all personnel at the Court;
- There are extensive changes in relation to the notification, certification and registration of deaths. This is to ensure that all deaths are properly reported and investigated where necessary. It also includes creating the new role of the State ‘Medical Examiner’;
- There is a new Appeals process, where an interested party can appeal to the Chief Coroner for review of a decision or verdict of a local Coroner, instead of having to issue a Judicial Review application.
3. Post Mortem Examinations
A post mortem may then be considered by the Coroner and unless the death is found to be due to natural causes, an inquest may be carried out. This is a decision for the Coroner to make, although it is possible for an interested person to an inquest to make representations to the Coroner on his decision. Should the Coroner decide to request a pathologist to undertake a post mortem examination the family cannot refuse such an order, even if this is in contradiction to religious or personal beliefs.
A family may not agree with the conclusions of the post mortem report; in such circumstances it is open to the next of kin of the deceased to request their own second post mortem examination to be carried out. We can advise on the steps and costs of such a request.
4. Inquest Procedure
Although the Coroner will set a date (normally some time ahead) for an inquest hearing, prior to this he will use the time to gather evidence including statements, factual documents and any other documentation, for example police reports etc. The Coroner may sometimes ask a member of the family to provide a statement.
The Coroner must notify any spouse, near relative and/or personal representative that an inquest is to be held.
The inquest investigation is ‘inquisitorial’ rather than ‘adversarial’. What this means is that all persons attending do so to assist the Coroner in his or her task of establishing the facts. There are no opposing parties and although witnesses can be questioned by the Coroner, the interested parties (or their representatives) there is generally no aggressive cross examination as can be seen in criminal or civil trials.
The Coroner has discretion as to who may participate in the inquest but parents, spouses and any personal representatives of the deceased would qualify as ‘interested parties’, who are entitled to attend, examine witnesses and make legal submissions. If a family is legally represented, then all questions will be expected to be asked through their legal representative.
It can often take some time for an inquest hearing to be listed as the Coroner’s Courts are generally over stretched. Under the new Coroners and Justice Act it is envisaged that all inquests should be heard within 1 year of the death, otherwise the Coroner will be expected to explain the delay to the Chief Coroner.
5. The Inquest Hearing
During the hearing, which is held in a Coroner’s Court, the Coroner may read out statements and after that s/he may then call those who s/he wishes to give evidence in person. In some inquests the Coroner may ask for an expert report from a doctor or technical expert. That expert will then be called to give evidence in relation to their report.
Unlike a civil or criminal trial the Coroner first asks questions of the factual witnesses and/or the expert witness(es) and only after s/he has finished questioning each witness will s/he then allow questions from any of the interested parties. Therefore, if the family is legally represented their legal representative will pose questions to each of the witnesses on the family’s behalf.
At the end of questioning of all the witnesses and/or experts, the interested party or their legal representative has the opportunity to make any legal submissions to the Coroner. Interestingly, no submissions are allowed to be made to the Coroner on the facts, unlike in criminal or civil trials where lawyers are expected to sum up the facts. This is generally the time to put any submissions to the Coroner on what sort of verdict you wish him or her to consider. If there is a Jury the coroner will then ‘direct’ the Jury on the possible verdicts.
Hospital Deaths
Where the death has occurred in hospital, the doctors involved in the treatment of the deceased will be called to give evidence, either in person or by means of a written statement depending on their involvement. The NHS Trust or operating company responsible for the hospital where the death occurred will also be legally represented if there is a possibility of criticism of the hospital staff. It is also possible that a manager from the hospital may be asked to give evidence, in particular in relation to hospital policy and procedure and whether there has been a system failure.
Jury
Most inquests are heard without a jury, but a jury must be called according to the Coroner’s Rules where:
- The death occurred in prison.
- The death was the result of an industrial accident (where notice is required to be given), poisoning or disease.
- The death occurred in police custody.
- The death occurred in circumstances where there is a possibility of recurrence or a same accident which would affect the health and safety of the public or any section of the public.
- There is suspicion of unlawful killing.
Other than above, in certain circumstances the Coroner has a choice as to whether to call a jury or not.
6. Adjourning an Inquest
If any person has been charged with murder, manslaughter or infanticide; causing death by dangerous driving; death by careless driving or under the influence of drink or drugs, or aiding, abetting, counselling or procuring the suicide of the deceased, the Coroner must adjourn the inquest until after the criminal proceedings have ended, unless the director of public prosecutions informs the Coroner that this is not necessary.
Also, during the inquest, having listened to the evidence, if the Coroner believes a person may be charged with a criminal offence s/he must adjourn the inquest and send the prosecuting authorities details of the evidence.
At the end of an inquest the Coroner will reach his or her verdict.
7. The Scope of Inquests
The Coroner’s Rules clearly state that the verdict at an inquest must not be expressed in such a way as to appear to determine any liability (either criminal or civil) on the part of any named individual. However, the Coroner does have a duty to hold a sufficiently wide enquiry to determine how the deceased died. The question of how a person died is not limited to establishing merely the medical cause of death but may also require an examination of the circumstances in which the death occurred. In certain circumstances this will mean enquiring into whether any lack of care actually contributed to the death. In the example of a hospital death, if the deceased was dependent on some form of care and there is a suggestion that care to a proper standard was not provided, the Coroner should enquire into whether a gross failure to provide care caused or contributed to the death.
European Convention on Human Rights – “Article 2 Inquests”
In certain circumstances the scope of the inquest may be widened to enable the State to comply with its duties under the European Convention on Human Rights (ECHR) to effectively investigate death. This area is quite complex but can be explained by one of our solicitors in detail.
The State’s duties arise from Article 2 of the ECHR which protects an individual’s right to life. This will only be triggered if the deceased was under the care or imposition of the state or an agency of the state at the time of his or her death. The European Court has held that the obligation to safeguard the lives of those within its jurisdiction imposes a duty on the State to put in place an effective, official investigation where the State was under a positive obligation to protect an individual’s life. An example of when a more detailed investigation would be required is where an individual dies as a result of the use of lethal force by state agents, for example police or army officers, or whilst under the care or protection of the State (prisoners or individuals detained under the Mental Health Act.)
The Courts have held that where a person is under the care of National Health Service staff, and the concern is in relation to how clinicians exercise their clinical judgement; an enhanced investigation will not be required by the Coroner in order to discharge the State’s obligation under Article 2. If a policy or system failure contributed to a death (whether in an NHS Hospital elsewhere) this in itself may trigger the need for an enhanced investigation.
The importance of an inquest under the Human Rights Act is that the Coroner or Jury has the ability to formally and publicly record any findings of failure on the part of the responsible State agencies that caused or contributed to the death. In such circumstances the Coroner or Jury may record any such failures as part of the verdict.
8. Funding
One of our team will be able to fully advise you about the funding options to cover the costs of representation at an inquest.
In certain exceptional circumstances the Legal Services Commission (previously known as the Legal Aid Board) can provide a grant of public funding for inquests through delegated powers from the Ministry of Justice. This grant is usually only awarded in cases which engage exceptional public interest or in ‘Article 2’ inquests. We can assess each case individually and advise whether to apply for a grant of funding. This grant will only cover the costs of representation at the inquest itself and not the preparatory work for the hearing.
Many people now hold Legal Expenses Insurance as part of their general household policies or credit card insurance which in certain cases may cover the costs of representation at the inquest. We will check all insurance policies you hold for possible cover.
It is often the case that the family members wish to pay privately for the cost of legal representation themselves; our team can provide a detailed estimate of the likely costs of representation and will keep you fully appraised throughout.
If there is likely to be a civil legal claim for damages to follow the inquest then it may be possible for us to offer a ‘conditional fee agreement / CFA’ to cover the costs of investigation and pursuit of a civil claim, part of which will include attending the inquest to gather evidence on your behalf.
Please contact us directly for advice on the different funding options open to you.
9. Disclosure of evidence
It is important to obtain as much evidence as possible prior to the inquest hearing. Although the Coroner is under no formal obligation to disclose witness evidence to the family or their legal representative, in practice it is becoming increasingly common that the Coroner will disclose such evidence. The Coroner is however always obliged to authorise disclosure of the relevant medical records as well as the post mortem reports, at the inquest.
The post mortem report can be particularly upsetting for the family members to read and sometimes it is better that this is disclosed directly to the legal representative, if the family requests this.
Back to top
10. Witnesses
It is the Coroner who generally decides which witnesses will be called to give evidence at the inquest and in what order. One witness that will always be called is the pathologist who will comment on the findings at the post mortem. The legal representative of any interested party/family is also allowed to make representations to the Coroner as to who should be called to give evidence. Once the Coroner has made a decision on the relevant witnesses. he will formulate a list which should be sent to the family or their representative in advance of the inquest hearing.
11. Pre-Inquest Meetings
It is becoming more common now to have meetings where the family’s legal representatives meet with the Coroner prior to the inquest hearing to discuss such matters as the order and number of witnesses and various matters of evidence that may be required/outstanding before the inquest. This is an ideal opportunity for you and your legal representative to look through all the evidence that has been provided and see if there is any missing information. It is also an opportunity to look at the list of witnesses and see if there is any other witness you consider would be very useful to help the Coroner to decide the facts and reach a verdict.
12. Verdicts
At the end of the inquest the Coroner will give his verdict. He will read this out and copies can also be requested after the inquest. The verdict is generally not in any set form although the Coroner’s Rules suggest possible verdicts including ‘accidental death’, ‘misadventure’, ‘natural causes’, ‘drug dependency’, and ‘suicide’.
There is a recent tendency for Coroners and juries to give what is known as a ‘narrative verdict’ which sets out in more detail the facts surrounding the person’s death. This is usually in the form of a descriptive paragraph or list, setting out the factors which made a material contribution towards the cause of death.
If it is not clear from the evidence to the Coroner as to what caused the death, then the Coroner may have to record an ‘open’ verdict.
Once the inquest hearing has been concluded a final death certificate can then be obtained and at this stage one of our team will advise you in respect of future steps such as pursuing a possible civil claim, although it is not always necessary to wait until the end of the inquest to bring such a claim. One of our Inquest Team will advise you in detail.
