About Inquests

The key stages to the Inquest process are:

Registering a Death / Referral to the Coroner

When a person dies, there is a statutory duty on a medical practitioner to issue a Medical Certificate of Cause of Death (MCCD), confirming the cause of death. Typically, the MCCD is provided by the treating hospital doctor or GP. Sometimes a cause of death cannot be properly determined or an MCCD properly issued / concluded. In such circumstances the death will be referred, usually by a doctor or the police, to the Coroner (an independent judicial office holder appointed by the local authority).

Cases typically passed to the Coroner are where the:

  • cause of death is unknown
  • death was violent or unnatural
  • death was sudden and unexplained
  • death was accidental
  • person who died was not visited by a medical practitioner during their final illness
  • medical certificate isn’t available
  • death was abroad
  • person who died wasn’t seen by the doctor who signed the medical certificate within 14 days before death or after they died
  • death occurred during an operation or before the person came out of anaesthetic
  • medical certificate suggests the death may have been caused by an industrial disease or industrial poisoning
  • there is actual or potential concern about a patient’s medical treatment

The Coroner’s office can provide some guidance as to whether the Coroner should get involved. If you are in any doubt about this, please get in touch and we can talk you through the process.

Once a referral has been made, the Coroner will then review the MCCD (Death Certificate) and decide what steps need to be taken. The Coroner will decide whether the cause of death is straightforward, or if there needs to be a post mortem examination.

Not every death referred to the Coroner will result in a ‘full’ Inquest or an actual Inquest ‘Hearing’. The Coroner has discretion to decide whether a full Inquest or hearing is required or merely an investigation– and equally – she/he can open and quickly close any such deaths referred, investigations and/or Inquests opened, as an entirely paper-based exercise.

Interested Persons

Individuals directly involved with a Coroner’s Inquest are known as ‘Interested Persons’. They are typically, close relatives, next of kin, or professionals involved with the care of the deceased; such as doctors, nurses, paramedics or police officers – particularly those who will be called upon by the Coroner to provide a witness statement or give evidence at the Inquest hearing.

Interested Persons can (and indeed have a right to) participate more actively in the Inquest process. They have a number of rights surrounding the provision of information – such as key dates, post-mortem / toxicology reports, and written evidence (witness statements, expert reports etc). Interested Persons are also given the chance by the Coroner to question the witnesses directly or through their legal representatives.

Please get in touch if you have any questions about your (or others) involvement at Coroner’s Court Inquest as an Interested Person.

Post Mortem Examination

A post-mortem (or autopsy) examination is a detailed medical examination of the body after death, carried out by a specialist pathologist. The purpose of a post-mortem examination is to determine the cause of death.

Following the examination and any necessary testing, such as toxicology and tissue analysis, a report detailing the cause of death is prepared for the Coroner.

An Inquest will be arranged if, following the examination, the cause of death remains unknown or the death was not found to be due to natural causes. Equally, the Coroner will have discretion to finalise her/his investigations and close the Inquest/investigation following post-mortem if appropriate.

After the post mortem examination, if the bereaved or other Interested Persons are still concerned about the cause of death, then they may ask for a second examination that they will have to pay for.

There are two types of post-mortem examination, a coroner’s post-mortem and a hospital post-mortem. A Coroner’s post-mortem typically takes place because the cause of death is unknown or following a sudden or violent death. A hospital post-mortem is generally arranged to find out more about an illness or cause of death, or to assist with medical research.

Hospital post-mortems can only be carried out with consent, whereas Coroner’s post-mortems can take place without the family’s consent – as the Coroner is required by law to carry out these examinations where appropriate.

If you have any questions in relation to post-mortem examinations, then please get in touch.

The Aim of a Coroner’s Inquest

The Coroner must open an Inquest into a death if there is reasonable cause to suspect that the death was due to anything other than natural causes or happened in state detention such as in a prison or in police custody.

An Inquest is a public, fact finding inquiry to determine the identity of the deceased (who) when, where and how they died.

The role of the Coroner is not to attribute blame or to determine any question of civil or criminal liability.

The Coroner is supported by a team of Coroners’ Officers. They help with the practical arrangements for the Inquest such as coordinating the pathologist, witnesses, medical experts, interested persons – as well as gathering any medical records and reports. They keep the bereaved family and friends up to date and respond to their queries.

Following the Inquest, the Coroner will give a ‘verdict’, or as they are now known, a ‘conclusion’. Possible conclusions that the Coroner will find are:

Death by natural causes – caused by the progression of a natural illness, not significantly contributed to by any human involvement, or

  • Accidental Death – where the cause of death was unnatural but not unlawful
  • Misadventure – similar to accidental death, although, misadventure suggests that an individual deliberately did something resulting in death
  • Neglect – where death is caused by a major failure to provide basic needs such as nourishment, liquid, warmth or medicine to a dependent person. There must be a link between the neglect and the cause of death but note – ‘neglect’ does not have the same legal meaning as ‘negligence’ in civil claims (e.g. clinical negligence claims).
  • Open – where there is not enough evidence to give a clear verdict/conclusion
  • Unlawful killing – by unlawful act or due to gross negligence manslaughter
  • Alcohol / drug related
  • Road Traffic Collision
  • Suicide
  • Stillbirth
  • Narrative conclusion – Coroners can detail the facts surrounding the death, including any findings on the main issues surrounding the cause of the death

After the hearing, the Coroner will prepare the paperwork (Record of Inquest) allowing the death to be registered and confirming the Inquest’s findings or conclusions as to the cause of death.

Prevention of Future Deaths Report

An important function of the Inquest, and power of the Coroner (under Regulation 28 of the Coroners (Inquests) Regulations 2013) is the option, indeed, duty to complete a ‘Prevention of Future Deaths Report’ (or ‘PFD’ report) in appropriate cases i.e. where it appears to the coroner that the investigation reveals a concern that a risk of future deaths will occur in similar circumstances in the future and action should be taken to prevent those circumstances.

These PFD reports come with a requirement for a response from the party subject to them. The response, e.g. from a Hospital Trust, GP Practice, Police or Ambulance Service, must contain details of action taken or to be taken to prevent such risk.

This is a quite powerful mechanism which allows the Coroner to deal with what we find, is usually a very important consideration for families involved with the Inquest process i.e. to have reassurance that any preventable circumstances surrounding the death of a loved one, are addressed – so that ‘this sort of thing can’t happen again to anyone else…’.

Pre-Inquest Hearings

In more complex cases the Coroner may order a Pre-Inquest Hearing to deal with a range of issues ahead of the main Inquest such as:

  • who are the Interested Persons
  • which witnesses will be called to give evidence in person
  • which witnesses’ written statements can be read out in Court without the need for them to attend – this often happens if what the witness is saying is uncontroversial
  • whether all the relevant evidence, such as medical records, has been disclosed
  • any expert evidence that may be needed, particularly where deaths are related to medical treatment
  • timetable for the hearing
  • any Human Rights issues to be looked at and whether a Jury is required
  • practical evidential arrangements e.g. the need for video link, translators etc
  • the need for a site visit

The pre-Inquest Hearing is a very important stage. To get the most from the process, it is vital that the families and other interested persons are clear on which witnesses are going to be called and what evidence will be available to the Coroner at the hearing. This may be the only opportunity that they have to get the answers they are looking for.

If a pre-Inquest Hearing has been arranged and you are not sure what to do next, then please get in touch. We are experienced in representing families and other interested persons at these very important hearings which crucially dictate the scope of, framework and evidence to be called at the Inquest.

The Inquest

Following completion of the Coroner’s investigations, an Inquest hearing date will be set. This will be confirmed with the family, Interested Persons, the witnesses and any experts giving evidence. If a witness is not willing to give evidence, then the Coroner can issue an order summoning them to the hearing, if they do not then attend then this could be contempt of court with severe criminal penalties.

Most Inquests are held in public, so the press and members of the public can attend.

Depending on how complex the issues are, an Inquest can last as little as a few hours or as long as several months.

At the Inquest hearing, all evidence is given on oath or read out in Court. The Coroner is addressed as “Sir”, “Madam” or “Ma’am”.

The Coroner controls the running order of the Inquest and having decided which witnesses will give evidence, will be the first to ask any questions followed by the Interested Persons or their legal representatives. The Coroner can intervene if the questions are inappropriate or irrelevant.

Following the evidence of the witnesses and experts, any legal representatives attending will have the chance to suggest possible verdicts or ‘conclusions’ to the Coroner. This is another crucial stage in the Inquest and is another reason why it is important to have experienced, expert and well-prepared representation. Please get in touch if you would like any further information about this.

The Coroner will conclude by summing up the evidence and comes to a conclusion (previously referred to as a verdict).

Sometimes, in more complex and longer running Inquests, the Coroner may take some time after the hearing to give a written verdict or will arrange a later, much shorter separate hearing to give the verdict.

Following the Inquest, it is possible to request a recording of the hearing together with any notes that the Coroner may have made. This is something we can help with and may be useful for family members and friends if they were unable to attend the hearing.

If you are in any doubt about whether you should have legal representation, then please get in touch and we can talk you through the process.

Can the conclusion be appealed?

It is very difficult to overturn the conclusion of an Inquest. This can be done by applying to the High Court for Judicial Review, strict time limits apply and such cases can only go ahead if it can be shown that during the Inquest process the Coroner acted unreasonably, unlawfully, irrationally or if there was important evidence that was not looked at or if there was a major irregularity in the way the Inquest was carried out.

It is very important to carefully consider getting professional experienced legal support and representation at the beginning of the Inquest process, as there is very little chance of being able to appeal the Coroner’s final conclusion. Inquest Legal does not provide assistance with judicial review of Coroner’s conclusions.

Please get in touch for an initial, free no-obligation discussion, if you are in any doubt about whether to arrange affordable, professional legal support at an Inquest you may be involved with.

Legal Representation

The bereaved are always entitled to have legal representation at the hearing. The Inquest is likely to be the only chance that the family or loved ones will have of finding out the cause of death and being able to directly ask those involved about the circumstance leading to the death.

Even if after the Inquest there are concerns that the right witnesses were not called, the correct evidence was not available or there was no appropriate expert evidence or there were concerns about the findings of the post mortem report, it is very unlikely that the Inquest will be re-opened.

By having expert legal representation from the very early stages, including before the pre-Inquest hearing, the Coroner can be clear on the family’s concerns and the investigation can be managed and prepared for properly.

Please get in touch if you would like more information about how Inquest Legal can help you through this difficult process with access to expert legal advice and representation on a fair, affordable, fixed fee basis.


Legal Aid

Other than in very rare or ‘exceptional’ cases involving human rights, or significant wider public interest issues – Legal aid is not usually available for representation at Inquests.

Because of this, most families must pay for legal assistance or representation themselves privately.

If you are worried about the costs of legal representation in preparing for and going to the Inquest, please get in touch for a no-obligation initial discussion to explore funding options.

Legal Expenses Insurance

This is a policy of insurance that is usually attached to a household contents policy or in the case of a death relating to a road traffic accident, motor insurance policy, that might meet relevant legal costs. It is important to check if any such policies exist and whether they cover the cost of legal representation at Inquests. Even if there is such a policy, many exclude this sort of representation and they also usually have strict deadlines within which to apply.

Some trade unions, professional indemnity policies of insurance and professional associations provide funding for Inquest representation, so it is important to check these sources too.

If you are unsure about whether you have any such cover or are worried about meeting the costs of legal representation in preparing for and going to the Inquest, please get in touch for a no-obligation initial discussion about funding.

Paying Privately

Usually, if bereaved families are unfamiliar with the legal process and want full answers to what happened, then they will need to pay privately for professional and experienced legal representation.

The Inquest can often be the only opportunity to get answers, so it may well be worth the investment in getting the most from the hearing through expert representation.

The Inquest is likely to be the only chance that the bereaved will have of finding out what happened from those directly involved, together with the reasons for and cause of the death.

The cost of representation at a hearing will vary from case to case depending on:

  • how long the Inquest will take
  • whether there will be a pre-Inquest hearing
  • the number of witnesses
  • the volume of medical records
  • the number of statements
  • the complexity of the issues
  • whether there is likely to be any expert evidence

Because of Inquest Legal’s low overheads and unique business model, we can pass this value to our clients, making expert legal representation at the Coroner’s Inquests affordable and accessible.

We are completely transparent with our fees which we will always agree with you up front on a fixed price basis, so no unexpected surprises. For a free initial, no obligation discussion about how we can help please get in touch.

Get in Touch

For more information about how we can assist you with an Inquest, Litigation Support for your Business or Medico-Legal training, click below to get started.