The medically-qualified practitioner who carries out a post–mortem examination.The medically-qualified practitioner who carries out a post–mortem examination.The place where a body is taken after its removal from the place of death.The place where a body is taken after its removal from the place of death.(also post-mortem(also postmortem) A medical examination to determine the cause of death, also called an autopsy.) A medical examination to determine the cause of death, also called an autopsy.(also post-mortem(also postmortem) A medical examination to determine the cause of death, also called an autopsy.) A medical examination to determine the cause of death, also called an autopsy.Young Offender Institution - prison for people aged 21 and underYoung Offender Institution - prison for people aged 21 and underA legal term (Latin for "under judgment") which means that a case is currently at trial or being considered by a judge or court, and so cannot be discussed in public.A legal term (Latin for "under judgment") which means that a case is currently at trial or being considered by a judge or court, and so cannot be discussed in public.Secure Training CentreSecure Training CentreA prosecution for a crime which arises for example from the circumstances of a death.A prosecution for a crime which arises for example from the circumstances of a death.The person who works for the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. and is responsible for making arrangements for the inquest.The person who works for the coronerThe legal official who orders a post-mortem and who is in charge of the inquest procedure. and is responsible for making arrangements for the inquest.The chief legal officer of the United Kingdom. It is a government cabinet position.The chief legal officer of the United Kingdom. It is a government cabinet position.Legal cases which are not criminal trials, sometimes involving a claim for damagesA payment of money in recognition of certain kinds of suffering or injury, also called damages./compensationA payment of money in recognition of certain kinds of suffering or injury, also called damages..Legal cases which are not criminal trials, sometimes involving a claim for damagesA payment of money in recognition of certain kinds of suffering or injury, also called damages./compensationA payment of money in recognition of certain kinds of suffering or injury, also called damages..Legal cases which are not criminal trials, sometimes involving a claim for damages/compensation.Legal cases which are not criminal trials, sometimes involving a claim for damages/compensation.A term used to describe proceedings in the High Court (such as a judicial review) when they are heard by two or more judges.A term used to describe proceedings in the High Court (such as a judicial review) when they are heard by two or more judges.Usually called clinical negligenceClinical negligence is a legal term for a medical accident where a patient has not received care to a proper standard, and that substandard care has also caused the patient a physical injury. Sometimes also called medical negligence., a legal term for a medical accident where a patient has not received care to a proper standard, and that substandard care has also caused the patient a physical injury.Usually called clinical negligenceClinical negligence is a legal term for a medical accident where a patient has not received care to a proper standard, and that substandard care has also caused the patient a physical injury. Sometimes also called medical negligence., a legal term for a medical accident where a patient has not received care to a proper standard, and that substandard care has also caused the patient a physical injury.The part of the Public Funding scheme that allows a solicitor to give advice for the preparation of an inquest for no cost if the client is on income support.The part of the Public Funding scheme that allows a solicitor to give advice for the preparation of an inquest for no cost if the client is on income support.Since 1 October 2009 the Supreme Court of the United Kingdom has taken over the judicial functions of the House of Lords. It is the court of last resort and highest court of appeal in the United Kingdom.Since 1 October 2009 the Supreme Court of the United Kingdom has taken over the judicial functions of the House of Lords. It is the court of last resort and highest court of appeal in the United Kingdom.The government's in-house lawyers, who will act for the Prison Service in instructing barristers at inquests.The government's in-house lawyers, who will act for the Prison Service in instructing barristers at inquests.The highest civil court where cases may be heard for the first time. It also hears appeals and conducts judicial reviewA type of court proceeding in which a High Court judge or judges reviews the lawfulness of the way a decision was made or and action was taken by a public body or official such as a coroner.s, and supervises magistrates and crown courts.The highest civil court where cases may be heard for the first time. It also hears appeals and conducts judicial reviewA type of court proceeding in which a High Court judge or judges reviews the lawfulness of the way a decision was made or and action was taken by a public body or official such as a coroner.s, and supervises magistrates and crown courts.Public means-tested financial assistance for representation during legal proceedings. It is not available for representation at most inquests. The Lord ChancellorThe cabinet minister in the government responsible for the effective running of the legal system in England and Wales. can grant it in exceptional cases.Public means-tested financial assistance for representation during legal proceedings. It is not available for representation at most inquests. The Lord ChancellorThe cabinet minister in the government responsible for the effective running of the legal system in England and Wales. can grant it in exceptional cases.The standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others.The standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others.The standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others.The standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others.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 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 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..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 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 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..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.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.The standard of
proof in a civil court cases and for inquest
verdicts other than unlawful killing or
suicide. In these cases, one outcome need
only be more probable than all the others.The standard of
proof in a civil court cases and for inquest
verdicts other than unlawful killing or
suicide. In these cases, one outcome need
only be more probable than all the others.Those 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.The organisation responsible for providing
Public Funds for legal work.The organisation responsible for providing
Public Funds for legal work.Formerly known as police surgeons, FMEFormerly known as police surgeons, Forensic Medical Examiners or police doctors examine and assess the medical needs of people detained in police custody.s or police doctors examine and assess the medical needs of people detained in police custody.Formerly known as police surgeons, FMEFormerly known as police surgeons, Forensic Medical Examiners or police doctors examine and assess the medical needs of people detained in police custody.s or police doctors examine and assess the medical needs of people detained in police custody.The DPP is a government-appointed legal officer who is the head of, and responsible for, the Crown Prosecution ServiceThe CPS is responsible for deciding whether or not there is enough police evidence to undertake a criminal prosecution for a general criminal offence (e.g. manslaughter) both before and in some cases after the inquest, and whether or not a prosecution is in the public interest..The DPP is a government-appointed legal officer who is the head of, and responsible for, the Crown Prosecution ServiceThe CPS is responsible for deciding whether or not there is enough police evidence to undertake a criminal prosecution for a general criminal offence (e.g. manslaughter) both before and in some cases after the inquest, and whether or not a prosecution is in the public interest..The ECHR 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.What verdicts can the inquest return?
There are a number of verdicts that can be given including:
• natural causes;
• industrial disease;
• dependence on drugs/non-dependent abuse of drugs;
• want of attention at birth;
• suicide/killed him or herself whilst the balance of his or her mind was disturbed;
• accident or misadventure (which means almost the same thing);
• disaster which is the subject of a public inquiry;
• attempted or self-induced abortion;
• lawful killing;
• unlawful killing;
• open verdict – this means that the cause of death cannot be established and doubt remains as to how the deceased came to their death;
• stillbirth;
• narrative verdictA form of verdict letting a jury give a longer explanation of what they think are the main or important issues..
In some cases the words “contributed to by neglect” can be added, but the law is very limited on when this can be applied and neglect does not mean the same in law as it does in everyday language. “Systemic neglect” can also be considered in some circumstances where evidence showed that insufficient action was taken to prevent a death.
All of these verdicts have to be established to the test within the balance of probabilitiesThe standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others.The standard of proof in a civil court cases and for inquest verdicts other than unlawful killing or suicide. In these cases, one outcome need only be more probable than all the others. except for suicide and unlawful killing, which have to be proved beyond reasonable doubtThe highest standard of proof required in legal hearings and needed for returning inquest verdicts of unlawful killing or suicide.The highest
standard of proof required in legal hearings
and needed for returning inquest verdicts of unlawful killing or suicide..
When does the coroner use the verdict ‘killed him or herself’?
When it is believed, on the basis of the factual evidence that the person genuinely intended to kill themselves. For this verdict to be returned there has to be clear evidence, for example a suicide note, which shows beyond reasonable doubtThe highest standard of proof required in legal hearings and needed for returning inquest verdicts of unlawful killing or suicide.The highest
standard of proof required in legal hearings
and needed for returning inquest verdicts of unlawful killing or suicide. that it was definitely the person’s intention to take their own life. If they did something that resulted in their death but there is not enough evidence that they intended to die, then this verdict cannot be returned.
What verdict is used if there is insufficient evidence that somebody had intended to kill themselves?
Misadventure, accidental death or an open verdict.
Would the verdict ‘killed him or herself’ have to be supported by a suicide note?
No, but that is a piece of evidence which could show intent.
What do accidental death and misadventure mean?
Accidental death means that the person died as a result of actions by themselves or others that had unintended consequences.
Misadventure is similar to accident but means that the deceased or others were carrying out an intended action (for example a planned surgical operation) but there was an unintended outcome (in this example, the death of the patient).
What does an open verdict mean?
This means that there is not enough evidence to return any other verdict.
What does unlawful killing mean?
This verdict means that the person was killed by an ‘unlawful act’ by someone or some others or as the result of their ‘gross negligence.’ These are both legal terms that are clearly defined in the criminal law. Unlawful killing is a very rare verdict.
If I think an institution (such as a prison or hospital) has neglected my relative, will that be included in the verdict?
There is a real difference between the meaning of ‘neglect’ in common speech and what that means in law. This is a complicated area and you should discuss this with your solicitor or one of the organisations on the links page. As indicated above, it is rare for the words “contributed to by neglect” to be added to one of the verdicts already mentioned. The verdict cannot state that any individual is guilty of neglect.
What is a narrative verdictA form of verdict letting a jury give a longer explanation of what they think are the main or important issues.?
In some circumstances, particularly in inquests where article 2 of the European Convention on Human RightsThe ECHR 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. applies (see Section 1.3: What is an inquest?), the jury can be asked to provide a narrative verdict. This allows the jury to expand on their verdict and give a longer explanation of what they think the main or important issues are. If you are legally represented, it is important to discuss this with your solicitor or barrister.
A narrative verdict can be a very powerful way of exposing any problems or mistakes that have been made, even though it will still not name any individuals as being to blame. If there are any disputes about what happened factually which are important, the narrative can include the jury’s decision on those facts. The jury should record any failings if these caused or contributed to the death.
Can the coroner make recommendations to prevent a further death occurring in similar circumstances?
The coroner has an important role in trying to prevent further deaths and under rule 43 of the Coroners Rules 1984, after the verdict the coroner may announce that they will write to any person or authority that has the power to take action to prevent future deaths.
This is referred to as a rule 43 report. The coroner is the only person entitled to make any comment in court after the verdict. Some coroners will allow lawyers to suggest things they think should be considered under rule 43.
Can the jury make any recommendations?
No. But as explained above in some circumstances they can write a narrative verdict including their concerns as long as they do not criticise a named individual.
Can the coroner’s recommendations be enforced and will I find out what response they received?
No. The relevant person or organisation is not under any obligation to act on the coroner’s recommendations, but under new rules introduced in the Coroners (Amendment) Rules 2008, they must reply within 56 days. The response should give details of any actions that have been taken, actions that will be taken, or explain why no action is going to be taken. The coroner must share these reports and any responses with any 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 (which includes the family) and with the Lord Chancellor.
How does the inquest finish?
The coroner and jury (if there is one) sign a document (Form 22, known as the inquisition) giving the findings of the inquest, which records the answers to the questions: who the person was, where they died, when they died, and how, i.e. the medical cause of death. You should be given a copy of this form.
