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.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.A form of verdict letting a jury give a longer explanation of what they think are the main or important issues.A form of verdict letting a jury give a longer explanation of what they think are the main or important issues.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.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.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.The 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.The 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.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.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.This section gives you specific extra information about the investigation of deaths that occur in circumstances where the quality of medical care may be an issue – for example in hospital or following treatment by a GP. You should read this section with the general sections in the guide.
Will there always be an inquest?
If you think that your relative has died as a direct result of poor medical treatment – either a failure to provide treatment or the treatment was mismanaged – then you should report your concerns to the coroner. If the coroner is not satisfied that the person died from natural causes or the cause of death is unknown, then they must hold an inquest to investigate and establish the cause of death.
The coroner should hold an inquest where there is reason to believe that negligent medical treatment may have caused the death. The inquest will normally be opened and then adjourned for further enquiries before the full inquest takes place. This can take from three to six months and sometimes longer.
Do I need specialist advice?
You may want to consider contacting Action against Medical Accidents (AvMA), a specialist organisation that runs a legal helpThe 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.line which you can call for detailed advice when there is a question about medical treatment. They have a specialist referral panel of lawyers and can refer you to an expert solicitor in your location if appropriate. They also can advise you on other legal options and may be able to help in preparing for this sort of inquest through their inquest advice service. Solicitors will usually provide a free consultation to discuss a potential claim about medical negligenceUsually 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. as well as whether inquest representation may be required.
AvMA’s helpline number is 0845 123 2352. AvMA have a specialist leaflet available on coroners and inquests (PDF).
What is medical or clinical negligence?
Words like negligence often have a different meaning in law than they do in everyday speech, and it is important to take advice on this. Clinical 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.
It is important to understand that the law defines clinical negligence as the failure on the part of the doctor or treating institution to reach the accepted standard of medicine.
Will there be a post-mortem?
The coroner will arrange a post-mortem examination by a pathologistThe medically-qualified practitioner who carries out a post–mortem examination.. If you are concerned about the accuracy of the post-mortem you may want to consider instructing your own independent pathologistThe medically-qualified practitioner who carries out a post–mortem examination. and a solicitor will be able to advise you about this (see Section 2.2 for more detailed information on post-mortems).
What needs to be done before a medical inquest?
As in all inquests it is important to obtain as much information as possible before the hearing. It is vital that whoever is asking questions at the inquest is as well prepared as possible and has the specialist knowledge to understand and analyse the medical issues being examined.
What information can I have access to before the inquest?
Unlike some other inquests more information may be made available to inform you before the hearing itself. In particular you are entitled to copies of the deceased’s medical notes and records under the Access to Medical Records Act 1990. These are usually held by their GP and the treating institution.
Once these records have been obtained a solicitor may instruct an independent medical expert to provide a report on any possible negligence. This can be of great assistance at the hearing itself. However, it is also open to your solicitor to request that the coroner instruct their own independent medical expert, which the coroner will pay for. The coroner does not have to then provide you with a copy of their report.
Should I find a solicitor?
If you think that the death of your relative may be due to poor medical treatment, and even if you are pursuing the complaints process, it is also advisable to contact a solicitor as early as possible. This will not halt the complaints process and will ensure you get advice in good time for an inquest, if one is to be held. Many medical deaths are not subject to an inquest; or the inquest, if held, is very limited in the issues it investigates. In which case it might require some considerable work by the family and/or their legal advisor to convince the coroner of the need for holding a full inquest.
This is a specialist area of law and you need to find a solicitor who is a member of the Law Society’s Clinical Negligence Accreditation Scheme and/or the AvMA referral panel and who has a Legal Aid franchise in the field, which are all indications of expertise in this area of law. It is particularly important to seek legal advice if you are worried that the coroner is not willing to take into account information you think is important.
How can I help the solicitor?
It is important that you write down your own account of the facts surrounding the death. Whether you are represented legally or not, you can ask the coroner to call evidence which you believe is relevant to the cause of death. However, in the end it is the coroner’s decision what evidence should be heard at the inquest.
What will happen at the inquest?
Have a good look at Section 4: which explains in more detail what happens. As already mentioned, it is important to understand that an inquest is not like hearings in other courts of law. The coroner is not allowed to decide any issues of civil or criminal liability on the part of a named individual. The inquest is purely a fact-finding exercise which can be frustrating for families who may want to hear more detail than the coroner will allow.
What should I do if I think the death was due to clinical negligence?
If you believe that negligent medical treatment may have contributed to the death and you are unsatisfied with any explanation put forward by the medical staff concerned, you may wish to make a formal complaint against the hospital, health trust or others. Again it can often be of assistance to contact AvMA who will be able to advise on the complaints procedure, how to prepare a complaints letter and may also be able to advise on the medical issues.
If AvMA are unable to assist they will be able to direct you to other agencies such as the Independent Complaints and Advocacy Service (ICAS). ICAS can provide support for patients and their families who want to complain about NHS treatment by attending complaints meetings with patients and helping with correspondence with the doctor or hospital concerned. However, it is important to remember that the complaints process can sometimes take a considerable length of time and there is no obligation on a doctor or Trust to respond to the complaint before an inquest, for example.
If I think there was clinical negligence involved in the death, will that be determined at the inquest?
No. The inquest is not the place to decide any kind of liability for the death. If you think there was medical or clinical negligence you need to obtain legal advice from lawyers with expertise in this area.
After the inquest
See Section 4.4: After the inquest.
After the inquest you may not wish to be involved in any more legal procedures. If you think there are important lessons to be learned from the inquest that might help prevent other deaths, you could consider contacting AvMA or another relevant campaign and/or speaking to your MP.
