Understanding the Coroner’s Inquest Process: Explained by a Legal Expert

Posted: 15th November 2023

Having recently dealt with a spate of estate administrations involving coroner’s inquests, Mike Cattermole TEP, a solicitor in our Wills, Trusts and Probate team, aims to explain the key aspects of the coronial process when a death is referred to the coroner.

A coroner’s inquest is a formal judicial inquiry governed by the Coroners and Justice Act 2009. It is convened to determine the identity of the deceased individual and the circumstances surrounding deaths that appear sudden, suspicious, violent or unnatural. The investigation is conducted by a coroner, typically assisted by a pathologist. For grieving families navigating the legalities around a loved one’s death, understanding the purpose and procedure of a coroner’s inquest can provide clarity during an extremely difficult time.

What Triggers an Inquest?

Under the Coroners and Justice Act 2009, an inquest is legally required when:

  • The cause of death remains unknown after a post-mortem examination
  • The death was violent or unnatural in nature, such as from suspicious circumstances, an accident, self-harm or otherwise
  • The death occurred in custody or detention
  • The death resulted from an industrial injury or disease within the past 5 years
  • The deceased was detained under the Mental Health Act 1983 when death occurred

Doctors hold a legal duty under the Births and Deaths Registration Act 1953 to refer any death lacking an obvious natural cause to the coroner. Additionally, a coroner holds discretionary power to conduct an inquest where a death was likely natural but an inquiry serves the public interest.

When an unexpected death occurs, the attending physician will be unable to issue a medical certificate citing the cause of death. This automatically triggers a referral to the coroner. However, even if the death initially appears natural, an inquest may still be required if the precise cause cannot be clearly ascertained upon further investigation or if the public interest demands an inquest be held.

The Post-Mortem Examination

Post-mortem examinations are governed by the Coroners and Justice Act 2009 and associated regulations. A coroner holds legal authority to order one, irrespective of family wishes. These autopsies are typically conducted promptly by a pathologist to determine the medical cause of death.

The post-mortem examination involves externally examining the body and internal examination of the organs. The latter requires surgical incisions which are sewn up afterwards. In some cases, minimally invasive or imaging-based autopsies may be performed. Tissue or organ samples may also be retained for additional laboratory testing. Families can request a doctor attend the autopsy to represent their interests, but this is rare.

If an inquest will be held, organ or tissue samples may be retained as evidence. Once released by the coroner, the family can view the body after the autopsy and prior to burial or cremation. Viewings provide an opportunity to say goodbye and gain a sense of closure. Though heart-wrenching, families are often comforted by the chance to see their loved one’s body one last time.

When a post-mortem fails to establish cause of death, the coroner assesses the need for further investigation and potential inquest. Pathology reports carry significant weight, so a cause of death stated therein is usually deemed conclusive. But if doubts linger, an inquest may proceed.

The Coroner Investigation

Beyond post-mortem examinations, coroners have additional investigative powers under the Coroners and Justice Act 2009. These powers include authority to enter relevant premises, seize evidence, require documentation production, and compel witness statements.

Coroner’s officers conduct investigations on the coroner’s behalf, gathering evidence through actions like interviewing witnesses, retrieving medical records, inspecting the scene of death, requesting toxicology tests, etc. Police officers often aid investigations in an advisory capacity where deaths are violent, suspicious or unexplained.

Investigations seek to uncover facts about the deceased’s medical history, activities preceding death, and any other pertinent circumstances. Their depth depends on the case complexity and cause of death obscurity. Rapid investigations are feasible when the post-mortem reveals an obvious cause of death.

The Inquest Hearing

Inquests are judicial inquiries governed by the Coroners (Inquests) Rules 2013. Their purpose is to publicly confirm the facts and circumstances surrounding controversial, unexplained or unnatural deaths.

Witnesses, including medical professionals, police officers and family members may be called to testify regarding the death in question. Interested parties like relatives hold entitlement to legal representation. Counsel can also represent witnesses.

Hearings usually take place in a coroner’s court and adhere to standard legal formalities. The rules of evidence do not fully apply, allowing coroners discretion to accept hearsay and documentary evidence. Witnesses testify under oath and face questioning from the coroner and other interested parties.

Potential outcomes of an inquest include accident, misadventure, suicide, natural causes, unlawful killing, etc. Where applicable, a jury determines the verdict as directed by the coroner. Inquests do not establish civil or criminal liability.

Prevention of Future Deaths

After conclusion, a coroner may issue reports to prevent future deaths in similar circumstances. These reports are sent to parties with power to implement the coroner’s prevention recommendations. They must respond within 56 days detailing actions taken or planned. Reports aim to improve public health and safety when systemic weaknesses or risks are uncovered.

Relatives can obtain documentation like the verdict, post-mortem findings and witness statements. Inquests are public events, enabling media attendance and public scrutiny. Transparency and open justice principles underpin the system.

However, restrictions apply in exceptional cases. For instance, national security interests or protection of vulnerable witnesses may necessitate anonymity or private hearings. Redacted documentation can also be issued. Coroners seek balance between public disclosure and sensitive privacy needs.

The Inquest Process

The Coroners and Justice Act 2009 imposes time requirements for completing investigations and inquests. The standard progression of events is:

  1. A reportable death occurs and is referred to the coroner
  2. The coroner evaluates the need for an inquest and opens an investigation
  3. A post-mortem examination is conducted
  4. Evidence is reviewed and relevant witnesses are identified
  5. An inquest hearing transpires with the coroner delivering a conclusion
  6. Final paperwork is completed and the death can be registered

Legally or medically complex cases may involve pre-inquest reviews and iterative stages. Most inquests seek completion within 6-9 months of the initial death report. Delays can be intensely frustrating and concerning for families, so coroners aim to conclude matters quickly while respecting thoroughness. Obtaining answers is critical, but not at the expense of rigour.

Family Rights and Support

Inquests can prove emotionally difficult and intimidating for grieving families. Having a single-family spokesperson, communicating concerns clearly to the coroner, and maintaining contact with the coroner’s officer can prove helpful. Practical guidance is offered by coroners’ staff throughout the process.

Legal representation for families is not funded by legal aid, but some pro bono assistance is available subject to capacity. Instructing specialist counsel on a private paying basis is advisable in legally complex cases or where negligence potentially contributed to death.

The presence of a friend for emotional support is often advisable throughout the inquest process. Reflection before speaking to media is also prudent. Press access can be restricted if staff have serious concerns about family welfare.

For advice, reputable organizations like Action Against Medical Accidents (AvMA), Cruse and Inquest can provide general or legal guidance. Such groups appreciate coronial processes are frequently obscure and daunting for newly bereaved relatives. Demystifying the system through education aligns with their charitable aims.

While undoubtedly painful, an inquest can furnish answers and closure after a traumatic loss. Understanding the requisite procedures and purpose can assist families in navigating this profoundly difficult experience. Empathetic coroners recognize inquests represent one small part of an agonizing journey for those deprived of a loved one.

When a Death is Suspicious

If evidence suggests a criminal element to the death, coroners adjourn inquests while police conduct homicide investigations. Criminal prosecutions take priority but require a higher evidentiary burden than coronial inquiries.

Following any criminal trial, the inquest is reconvened or closed as appropriate. A guilty verdict necessitates only a basic inquest confirmation of unlawful killing. But acquittals or discontinued prosecutions enable full inquest proceedings to determine cause of death based on the balance of probabilities.

The coroner has power to refer any evidence of criminality unearthed during an inquest to the Crown Prosecution Service. So findings potentially initiate a fresh criminal investigation by police. Parallel criminal justice and coronial processes can prolong resolution for families in some cases.

Deaths Abroad

When a British national dies overseas, local authorities in the country where death occurred hold jurisdiction over investigating cause and circumstances.

However, next-of-kin can request the UK coroner open an investigation if dissatisfied with the foreign inquiry’s scope or findings. The UK inquest relies upon evidence gathered abroad, and cannot compel overseas witnesses to participate. But a UK inquest and determination of cause of death can provide peace of mind to grieving families.

Institutional Deaths

Deaths of detained individuals in state institutions like prisons, police custody, or psychiatric hospitals automatically require a coroner’s inquest. This reflects public concern over institutional deaths, where neglect or maltreatment may potentially contribute.

In contentious institutional cases, inquests offer a crucial opportunity to rigorously explore the circumstances and establish facts. As public events, they can impartially and transparently determine whether deficiencies in systems or procedures contributed to death and make recommendations for improvements.

The scope of institutional inquests includes examination of factors like detention conditions, staff supervision, emergency response, medicine provision, mental health, substance misuse, training, etc. Juries are frequently summoned to bolster public confidence in the independence of proceedings and conclusions reached.

While EMG Solicitors are unable to provide representation at inquests, our experienced solicitors can guide and support families through all aspects of administering a loved one’s estate compassionately and efficiently.