Section 1.3: What is an inquest?

It is an investigation held in public to establish who the person was, and where, when and how they died. It is a legal procedure presided over by a coroner in the public interest:

• to find out the medical cause of death;
• to draw attention to the existence of circumstances which, if nothing is done, might lead to further deaths;
• to advance medical knowledge;
• to preserve the legal interests of the deceased person’s family or other interested parties.

What is a coroner?

A coroner is appointed by the local authority in which his or her court lies. They are judicial officers and can only be removed from office by the Lord Chancellor. Coroners are either solicitors or barristers, and/or qualified medical practitioners with at least five years’ experience.

What is a coroner’s officerThe person who works for the coroner and is responsible for making arrangements for the inquest.?

Coroner’s officerThe person who works for the coroner and is responsible for making arrangements for the inquest.s are the staff in the coroners’ courts that bereaved families will have most contact with before the inquest. The role of coroner’s officer is often filled by either a retired police officer or a serving one on secondment from a local police force. Coroner’s officers who are not serving police officers would be employed by the local authority.

When do inquests happen and who has the power to decide?

The Coroners Act 1988 sets out the duties of a coroner and in what circumstances he or she should hold an inquest and in what circumstances he or she has the choice to do so.

This can be summed up as follows:

• where there is reasonable suspicion that someone has died a violent or unnatural death;
• where someone has died a sudden death and the cause is unknown;
• where someone has died in prison or in any place or circumstance where there is a legal requirement to hold an inquest because of an Act of Parliament.

When will a doctor refer a death to a coroner?

A doctor must refer the death to the coroner:

• If a doctor is not able to issue a medical certificate as to the cause of death when called to see someone who has died, for example, because they are uncertain about the cause of death;
• if someone has been admitted to hospital less than 24 hours before their death;
• if the cause of death is violent or unnatural.

Who else may report a death to a coroner?

• The police.
• A registrar of deaths, for instance if the cause of death appears to be due to industrial disease or poisoning.

If a death is reported to the coroner, is an inquest always held?

No. After initial examination of the evidence, a coroner may decide that an inquest is not necessary. He or she will send details to the registrar confirming that the death is natural.

Why must an inquest be held?

Because the cause of death is uncertain or unnatural.

There are a number of circumstances where it would be expected that an inquest would be held, including:

• No death certificate was issued because a doctor was not present at or before the death.
• No medical attention was given for an illness which occurred just before the death.
• No medical examination was made by the doctor issuing the death certificate during a period of 14 days before the death.
• Death during or immediately after an operation, or following administration of an anaesthetic.
• No known cause of death.
• Reasonable cause to suspect that a death was unnatural, due to violence, neglect, abortion or in suspicious circumstances.
• Death due to industrial disease or poisoning.
• Death occurred in prison; in police custody or following police contact; or during detention in a psychiatric hospital.

The vast majority of deaths are not referred to the coroner for an inquest. Of the average half-million registered deaths in any given year, about 230,000 are reported to coroners. There are inquests held into around 31,000, or about 13%, of such deaths each year, according to figures published in May 2010.

What is an unnatural death?

One that was due to actions or omissions that led to a clear event, which ultimately led to the person’s death.

Who has the right to ask questions at an inquest?

Properly interested personThose people defined in the Coroners Act 1988 as having a right to ask questions at the inquest. Family members such as parents, children, spouses, civil partners or partners of the person who has died automatically come within the definition and can ask questions at the inquest. Other relatives and those with close relationships may also be regarded as Properly Interested Persons.s, as set out in rule 20 of the Coroners Rules 1984. See Section 3.1: Legal advice and how to fund it for further explanation of who is a properly interested personThose people defined in the Coroners Act 1988 as having a right to ask questions at the inquest. Family members such as parents, children, spouses, civil partners or partners of the person who has died automatically come within the definition and can ask questions at the inquest. Other relatives and those with close relationships may also be regarded as Properly Interested Persons..

If an operation is likely to have led to a person’s death is an inquest necessary?

Not if the cause of death is natural, e.g. if the death of an older person was due to a stroke or if the chance of the operation’s success was very low. However, it is often an area of dispute and you should seek legal advice if you do not accept the coroner’s decision not to hold an inquest (see Section 3 on legal advice, and also the part of Section 5 on deaths following medical treatment).

If you think an inquest should be held what should you do?

Representatives of the family should make their views or concerns known to the coroner as soon as possible after the death. They can contact the coroners court by post, by ringing the court and talking to the coroner’s officer, or in some cases by email. It is also a good idea to put any concerns you have to the coroner in writing. You should also consider getting legal advice as soon as possible.

Will there be a jury?

Not in the vast majority of inquests, but in certain cases the law says the inquest must be held in front of a jury. When the state has had care of the individual prior to their death, such as in prison or in police custody, the inquest is required to meet particular standards under article 2Article 2 of the European Convention on Human Rights says that the state must not take someone’s life, except in very limited circumstances. The effect of article 2 is that the state has a duty to protect life and to carry out an effective investigation into a death involving the state or state agents. An inquest is normally the way which this is carried outArticle 2Article 2 of the European Convention on Human Rights says that the state must not take someone’s life, except in very limited circumstances. The effect of article 2 is that the state has a duty to protect life and to carry out an effective investigation into a death involving the state or state agents. An inquest is normally the way which this is carried out of the European Convention on Human Rights says that the state must not take someone’s life, except in very limited circumstances. The effect of article 2 is that the state has a duty to protect life and to carry out an effective investigation into a death involving the state or state agents. An inquest is normally the way which this is carried out of the European Convention on Human RightsThe ECHRThe European Convention on Human Rights is an international treaty to protect human rights and fundamental freedoms in Europe, incorporated into UK law as the Human Rights Act 1998. All Council of Europe member states including the UK have signed the Convention. is an international treaty to protect human rights and fundamental freedoms in Europe, incorporated into UK law as the Human Rights ActThe Human Rights Act 1998 is an Act of Parliament that incorporated the European Convention on Human Rights into UK law. 1998. All Council of Europe member states including the UK have signed the Convention. (which sets legal standards to protect the right to life). These are often referred to as article 2Article 2 of the European Convention on Human Rights says that the state must not take someone’s life, except in very limited circumstances. The effect of article 2 is that the state has a duty to protect life and to carry out an effective investigation into a death involving the state or state agents. An inquest is normally the way which this is carried out inquestAn inquest into a death involving the state or state agents is required to be, in many ways, more thorough and wide ranging than inquests that do not engage the duties required by article 2 of the ECHR.An inquest into a death involving the state or state agents is required to be, in many ways, more thorough and wide ranging than inquests that do not engage the duties required by article 2 of the ECHR.s and will have a jury (see below).

The Coroners Act 1988 says in section 8 that juries are required in a number of situations, including when:

• The death occurred in prison (see Section 5.2: Deaths in prison) or in such circumstances as to require an inquest under any Act other than the Coroners Act 1988.
• The death occurred while the deceased was in police custody, or resulted from an injury caused by a police officer in the purported
execution of his or her duty (see Section 5.1: Deaths in police custody or following police contact).
• The death was caused by an accident, poisoning or disease, notice of which is required to be given under any Act to a government department, or to any inspector or other officer of a government department or to an inspector appointed under section 19 of the Health and Safety at Work Act 1974 (see Section 5.4: Work-related deaths).
• The death occurred in circumstances the continuance or possible recurrence of which is prejudicial to the health or safety of the public or any section of the public.

Only a minority of the inquests held each year have a jury. For example, of the nearly 31,000 inquests held in 2009, only 466 (1.3%) were held with a jury.

What is an article 2 inquestAn inquest into a death involving the state or state agents is required to be, in many ways, more thorough and wide ranging than inquests that do not engage the duties required by article 2 of the ECHR.An inquest into a death involving the state or state agents is required to be, in many ways, more thorough and wide ranging than inquests that do not engage the duties required by article 2 of the ECHR.?

In some circumstances article 2 of the European Convention on Human Rights, often referred to as the right to life, means that the state has a duty to carry out an effective investigation into a death. The inquest is normally the way which the state carries this out and inquests held in these circumstances are now referred to as article 2 inquests. They are required to be, in many ways, more thorough and far-reaching than inquests into deaths that do not engage this duty.

Article 2 says that the state must not take someone’s life, except in very limited circumstances, and it imposes a duty on the state to protect life, so there must be a proper and thorough review of how someone died. Examples of article 2 inquests include where individuals died as a result of the use of lethal force by state agents (such as police officers) or while under the care or protection of the state (such as prisoners or other people known to authorities to be at real and immediate risk of harm). This is a complex area of law and if you have questions about whether this applies to your relative’s death you should seek advice from a solicitor.

What information will I be given about the inquest by the coroners court?

You should receive a leaflet from the coroner’s court called A Guide to Coroners and Inquests. If you do not receive this leaflet, ask for a copy and it is also available online (see question below). In some areas coroner’s officers give this information automatically but in others they do not have copies of the leaflet. You should ask questions of the coroner’s officers if there is anything you are not clear about.

Is there general information available online that may be helpful?

The website www.direct.gov.uk has some very useful information. Go to the section headed Death and Bereavement where you will find a range of helpful information.

See also the website details of the organisations listed on ourlinks page.

What is a death certificate?

A death certificate is a legal document that is sent to the registrar of births and deaths, to record the details of a person who has died and the cause of death. When there is an inquest the coroner will issue an interim certificate when the body is released but will not issue a final death certificate until after the inquest has concluded. An interim death certificate is necessary to enable the body to be released in order for a funeral to be held and for the administrative procedures that follow a death.

When will the inquest be held?

In most circumstances the inquest will be opened very soon after the death for the formal business of recording the person’s identity. This is a very short procedure taking only a few minutes, and it may be held in the coroner’s office and not in a court room. You have the right to attend this hearing.

After that, the length of time before the full hearing depends very much on the geographical area where the inquest is taking place and the nature of the circumstances surrounding the death. Where there are other investigation procedures to go through it can be a number of years after the death before the inquest is held.

Where will the inquest be held?

In some places, particularly large metropolitan areas and cities, there will be a specific coroners’ court. In London there are eight coroner’s courts which each cover a group of boroughs. In smaller towns it may be held in the magistrate’s court or possibly in a room in the town hall. Jury inquests have sometimes been held in a local crown court.

Will the inquest establish who is responsible for my friend or relative’s death?

No. The main purpose of an inquest is to establish the cause of death. It cannot blame individuals for the death or establish criminal or civil liability on the part of any named individual(s). Coroners will often say at the beginning of the inquest that their job and that of the jury (if there is one) is to establish the answers to four questions – who the deceased was, where they died, when they died, and how.

But surely how they died includes who was responsible?

No. According to the law it is not the function of an inquest to blame particular  individuals involved. The inquest might make criticisms about what happened, but cannot suggest that any individual is liable for someone’s death. Many people are shocked and very disappointed to learn that the inquest cannot seek to establish who may be responsible for the death.

Will the inquest look into all the issues and circumstances of the death?

As explained, the remit of the inquest is legally very narrow. It may be that there are many events in the days, weeks and even months before the death which you believe played a part in the death. It will depend on the circumstances of the death as to which evidence the coroner thinks is relevant. Individual coroners will have different approaches and some will allow more questions than others.

Will I be able to see the evidence and statements before the inquest?

Usually it is for the coroner to decide whether written evidence will be disclosed (copies sent) to a bereaved family before the inquest.

Although you do not have a legal right to have such disclosure the coroner must make their decision about this on the basis of what is fair in the circumstances. If the coroner agrees to release some of the evidence or statements, he or she may do on the basis that all reasonable charges are met by those requesting the material. In many cases, this will mean costs involved in photocopying the evidence or statements. It is always advisable to make sure of any charges involved when a request is made for copies of any evidence or statements.

However, where someone has died in custody, the police, Prison Service and coroner have various guidelines which in principle mean that they should provide the family and their lawyers with all the evidence before the inquest to assist them with their preparation.