Inquests

The Coroner has a duty to investigate and hold an inquest where there is a reason to suspect that an individual died a violent or unnatural death, the cause of death is unknown, or the individual died while in custody or otherwise in state detention.

An Inquest is an inquisitorial, not adversarial, process and seeks to ascertain who, when, where and how the individual came by their death. However, despite its fact-finding agenda, inquests can still feel adversarial and it can be valuable to seek legal advice in the early stages to ensure you / your organisation’s interests are represented.

Inquests do not…

Apportion blame.

Determine any question of criminal or civil liability – although civil claims can arise following inquests and findings can be used in those proceedings.

Investigate beyond the scope allowed under the legislation and regulations.

The Coroner – appointed by the Local Authority, a legal or medical professional (some sit part-time as an Assistant Coroner)

Interested Persons (IPs) – organisations or individuals who take an active role in proceedings. This may include the family of the deceased. They are usually legally represented, and receive disclosure before the final hearing, they may ask questions of witnesses and make submissions on legal issues which arise. IPs can also be the subject of directions from the Coroner to take specific steps . You may be appointed as an IP from the outset or can make an application to the Coroner. These applications are usually determined early in proceedings.

Experts – Coroners can appoint medical or other experts to assist in the investigation

Jury – There is a presumption against having a jury in Inquests and the conclusion is usually determined by the Coroner alone. However, juries are mandatory in some cases such as where the individual died in custody or due to an act or omission by the police in purported execution of their duty. The need for a jury can be debated between IPs and the Coroner may consider legal submissions before taking a decision.

The Coroner will make directions to gather evidence from various organisations and IPs, by identifying witnesses, requesting witness statements, seeking documentary evidence (such as medical records) and appointing experts.

Reports may be sought from relevant organisations such as the police, the Health and Safety Executive, mental health services etc. This will depend on the circumstances of the individual’s death.

Witness statements can be submitted from key individuals, who might later be called to give oral evidence.

Pen portraits are also sometimes prepared by legal representatives for the family, which provide an insight into the individual who has died.

Depending on the complexity of the facts, Coroners can direct pre-inquest review hearings to determine preliminary issues such as:

Disclosure

Identifying witnesses (and which will be called vs. their evidence being read)

Timetabling

Consideration of legal submissions on contested issues such as scope, jury and Article 2*

Article 2 of the European Convention on Human Rights places obligations on the state (and therefore public bodies) to protect life, and is both a procedural and systemic duty. Where Article 2 is engaged, the Coroner will ascertain not just died but in what circumstances. This affords a higher level of scrutiny and can increase the length of proceedings to fulfil the duty to ensure detailed and transparent investigation.

At the final hearing, the Coroner will determine the order of the evidence to be heard.

IPs can question each witness and the witness’ own representative, if they have one, may also ask questions.

The Coroner has broad discretion to manage proceedings and can disallow questions which they consider to be irrelevant or outside the Inquest’s scope.

Once all witnesses have given evidence, the Coroner sums up the evidence.

The Coroner (or jury) will then make a determination of the matters ascertained during the investigation.

This is called the “conclusion”, and there are different findings open to the Coroner. Where Article 2 is engaged, the Coroner is more likely to give a narrative conclusion which sets out in more depth the circumstances relating to the individual’s death.

The conclusion and findings are then recorded as part of the process for formally registering the death.

Where the evidence suggests that further avoidable deaths could occur, the Coroner has a duty under the Regulations to make a Prevention of Future Deaths (PFD) report to the relevant organisation outlining the preventative action that should be taken.

The duty can be triggered by “anything revealed” during the proceedings, not just where acts / omissions caused or contributed to the individual’s death.The report will be sent to the relevant person or organisation, who are under a mandatory duty to reply within 56 days. PFD reports are also published.

To mitigate the risk of a report being issued, relevant organisations must identify potential issues at an early stage and take appropriate action to improve services in advance of the hearing. This might require a comprehensive internal analysis of process and procedure, or even opening an investigation.