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.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 information about the investigation of deaths that occur at work or that are related to the workplace. You should read this section with the general sections in the guide.
What is a work-related death?
A work-related death is defined by the Health and Safety Executive (HSE) as: “a fatality resulting from an incident arising out of or in connection with work.” It covers:
• The death of a worker during the course of his or her employment.
• The death of a member of the public arising from work activities.
• The death of a member of the public in an incident like a train crash.
• Some work-related road deaths which require an investigation into a company’s working practices, such as a lorry driver working excessive hours.
The common feature of all these deaths, whether they involve a worker or a member of the public, is that they raise questions about whether the working practices of a company or organisation were adequate or not.
Will there be an inquest?
You would normally expect an inquest to take place following a work-related death. An inquest is required when a death is “unnatural” which is likely to be the case in most work-related deaths. In most cases the inquest will be heard in front of a jury.
Who investigates work related deaths?
All work-related deaths will be reported to one of a number of regulatory bodies, depending on where the incident took place and the circumstances surrounding the death:
• The Health and Safety Executive (HSE) and local authorities which are responsible for the investigation and prosecution of health and safety offences.
• The Maritime and Coastguard Agency (MCA), which is responsible for the investigation and prosecution of offences when the death takes place in British waters or on a UK-registered ship.
• The fire authorities, which are responsible for the investigation and prosecution of fire safety offences when the death is a result of a fire.
• The police, who will investigate whether or not the death was the result of manslaughter by a company or an individual.
• The Crown Prosecution Service (CPS), which is responsible for deciding whether any individual or company should be prosecuted for the offence of manslaughter.
The purpose of these investigations are:
• to make sure that there are no continuing risks and make the situation safe;
• to undertake a criminal investigation.
Should I obtain legal advice?
If you have any concerns about the investigation or the inquest, or if you want to consider making a claim for compensation, you should take further advice, including legal advice. You may find that a solicitor is only interested in issues relating to compensation, whilst you are concerned about issues of accountability. Compensation (also called damages) is one important way of establishing accountability if an employer has been negligent.
Unfortunately, since the employers’ insurance will probably pay for the compensation, many families do not feel this is an adequate way to hold them to account. That is why it is important to ensure that there is a good investigation by the police and the regulatory agencies and that proper consideration is given to whether the company and/or an individual should be prosecuted.
Can a trade union help?
If the bereaved person was a member of a trade union, the union may provide you with free legal representation at the inquest and help you in any claim for compensation. The trade union may be able to take further action, particularly in relation to any safety issues for the company involved.
Can anyone be prosecuted if mistakes have been made?
Work-related deaths often lead to questions about the practices and safety standards of an employer and there may be grounds for criminal charges. There are two sorts of offences that could have been committed in relation to a work related death:
• an offence under regulatory law like the Health and Safety at Work Act 1974, requiring evidence of systemic failures in working practices;
• an offence of manslaughter, which requires evidence of gross negligence.
The criminal investigation Work Related Deaths: A Protocol of Liaison was established in April 1998 encouraging the importance of the investigatory bodies working together to investigate thoroughly, and to prosecute appropriately, those responsible for work-related deaths in England and Wales. The Protocol can be obtained from the HSE and is available on the HSE website (PDF).
In every case a police officer of supervisory rank (sergeant or above) should come to the scene of the death and undertake an initial assessment of whether a full-scale manslaughter investigation should take place. If the officer decides against it, the case is referred to the HSE or one of the regulatory bodies noted above. The investigating body can refer the case back to the police at any time during the course of the investigation if there is “evidence that indicates that manslaughter may have been committed.”
The investigation: what should you expect?
This can take several months to complete. During this time the police and the HSE will conduct interviews with key witnesses, instruct experts, analyse evidence collected on site, look into the working practices and/or activities which caused the fatality, keep the coroner updated with the progress of the investigation and investigate the conduct of senior managers and company directors with particular responsibility for the day to day running of the organisation.
The HSE should appoint a named person or a Family Liaison Officer (FLO) to keep you informed of developments during the investigation. If you have any concerns with the investigation, raise these with your FLO or the named contact you have from the HSE.
You can read more about how the HSE investigates work-related deaths here (PDF).
What will happen at the inquest?
If a manslaughter investigation is taking place, a full inquest will be delayed until after a criminal trial. It is then up to the coroner to decide after the trial whether there will also be an inquest. It is extremely unusual for there to be an inquest after a criminal trial. If there is no manslaughter investigation, and only the HSE is investigating, the inquest will take place before the HSE decides whether or not to prosecute. This is likely to be about 12-18 months after the death.
It is important that you ensure the coroner knows what witnesses you want to be called to the inquest. You or your legal representative should write to the coroner listing the witnesses you want to attend. It is not uncommon for coroners to decide not to call company directors or managers. This often means that crucial evidence indicating failures on the part of the company may not be heard at the inquest. This can then mean that a jury is
prevented from giving an unlawful killing verdict even when this might seem appropriate.
Can I see the documents created during the investigation?
No, there is no pre-inquest disclosure of documentary evidence. Unlike inquests into deaths in prison and in police custody, the regulatory authorities like the HSE refuse to hand over any documents before the inquest. They will however give some documents to the coroner. Ultimately the coroner will decide what documents can be released to the bereaved family at the pre-inquest stage and it is important to request copies of all documents.
What verdict can the inquest reach?
The verdicts that can be left to a jury, if the evidence supports it, after a workplace death inquest are:
• Unlawful killing – where a worker died as a result of conduct on the part of some individual considered to be “grossly negligent.”
• Accidental death – this covers a large range of situations, from a mishap to a death caused by conduct which would be considered to be negligent but is not so negligent that a verdict of unlawful killing is appropriate. It may be followed by a written narrative identifying any systemic failures in working practices which may have come to light during the inquest.
• Open verdict – when the evidence given does not disclose enough about how someone died, for instance if there was no eyewitness, so there is not enough evidence to return another verdict.
Can the HSE prosecute after the inquest?
Yes. The HSE will decide after the inquest whether to prosecute for health and safety offences. It only prosecutes companies in about 20% of workplace deaths. 70% of these prosecutions take place in the magistrates’ court rather than the Crown Court, where there would be the possibility of an unlimited fine. The failure to prosecute in the Crown Court has meant that the average fine for a conviction following a workplace death is just over £18,000.
The HSE very rarely prosecutes senior managers or directors. Between 1996 and 1998, the HSE did not prosecute a single manager or director relating to any one of over 500 workplace deaths. It is therefore important to make sure that you or your legal representative looks carefully at the decisions made by the HSE.
In particular:
• make sure that they have considered properly whether to prosecute a company director or manager;
• make sure that, if they prosecute, they make attempts to get the magistrate to refer the case to the Crown Court.
In the event the HSE decide not to prosecute, make sure you scrutinise the decision – ask for detailed reasons why they are not going to prosecute the company and/or senior manager(s) or directors. You may prefer to meet the HSE to raise your concerns about the decision as well as writing to them.
What information will I get from the HSE?
The HSE has a policy of providing information to bereaved families once the case has been formally closed. At the beginning of every case, a HSE inspector should make contact with you both by letter and personally. It is also the HSE’s policy to explain their involvement, give details of the investigation, its conclusions, including the circumstances of the death and explain what action is to be taken and the reasons for such actions.
Make sure that you make use of this right to be kept informed by the HSE of what they are doing. Don’t feel shy of making your views known to them or providing them with any information that you feel might help their investigation. It is our experience that often families may get to know of information that is not known by the HSE.
After the inquest
See Section 4.4: After the inquest.
You may also want to raise any concerns about what happened after you have heard all the evidence at the inquest.
You could consider contacting:
