How to guide: Being called to give evidence at an inquest

Directors, managers and employees from all manner of companies and organisations can be called to give evidence at inquests — sometimes about things they have personally done or seen, but sometimes also about the company’s/organisation’s policies and procedures. Many witnesses at an inquest will have no prior knowledge or experience of the coronial process. This article seeks to provide some basic guidance for witnesses giving evidence at an inquest.

What is an inquest and what is it seeking to achieve?

An inquest is an investigation into a death which appears to be due to unknown, violent or unnatural causes. The inquest is required in law to answer the four statutory questions; who, where, when and how, that is, by what means did the deceased come by their death. The answer to these questions enable the coroner to decide upon the medical cause of death, and to give a conclusion. Inquests will also be held if a member of the public has died in state detention, i.e. custody, prison or as a psychiatric in-patient who has been sectioned.

The process will also examine any matters surrounding the death to establish whether any actions or omissions by those involved contributed to or had an influence on the death, for example, the police, the medical team, social workers etc.

Who is the coroner?

Coroners are Independent Judicial Officers responsible for investigating violent, unnatural, sudden deaths where the cause is unknown or where the person died while in custody or otherwise in state detention. They are appointed and paid by the relevant local authority. Any coroner appointed after July 2013 has to be legally qualified. However, if the coroner was appointed prior to this date they can be either a doctor, a lawyer, or both.

Who are the witnesses/ interested persons?

The coroner must piece together all of the relevant information surrounding the events leading to the death in order to carry out a comprehensive investigation.

As a fictional example, Joe Bloggs died on 16 November 2023. In the months prior to Joe’s death, he suffered a life-changing injury at work in his job with the local authority. He spent time in hospital. His mental health deteriorated. He was referred to mental health services when he was released from hospital. He committed a crime when drunk and was arrested. He was charged and sent to prison. He was released from prison and assigned a probation officer. He began living in approved premises, also known as a probation hostel. He sadly took his own life.

In order to understand how Joe came about his death, the coroner would speak to the following interested persons:

1. Joe’s workplace
2. The hospital
3. Joe’s GP
4. The mental health services
5. The police
6. The prison
7. The probation service
8. The probation hostel

The coroner needs to understand how the above organisations work together. The coroner will try and ascertain if there is anything that could or should have been done and what learnings have come from the death of Joe. There may be several witnesses for each of the above interested persons. The coroner will also be interested in the policies in place for each organisation at the time of Joe’s death. For example, could Joe’s workplace have better safety measures in place to prevent injury? Were the probation office aware from the prison that Joe may have been suffering from poor mental health upon his release and, if so, was his accommodation appropriate? What support was he offered when he was released? Could communications between the agencies have been better?

This is one example but as you can see, inquests can be very far reaching and involve many witnesses.

If I am called to give evidence, am I obliged to attend?

You have been asked to attend by the coroner because they believe that you have evidence that can assist with the question of how the deceased died. If you have received a formal “Summons” to attend court then you are legally required to attend. If you do not, the coroner can impose a fine of up to £1000 for contempt of court. Even if you have not received a formal Summons but the coroner has said that they require your attendance then you are still required to attend. If you do not the coroner can then issue a Summons.

Who asks questions at the inquest?

You will be asked to sit in the witness box and then give an oath or affirmation. The coroner will be the first person to ask you questions. You should address the coroner as “Sir” or “Ma’am”. Usually, the family will ask questions next and then the coroner will ask the other ‘interested persons’ if they have any questions for you. Your own legal team act as your safety net and will ask questions last to clarify anything you have said, if necessary.

What happens if I cannot remember?

Giving evidence is not a memory test. Inquests often happen some considerable time after the event — nobody is expecting you to remember things perfectly. You will already have read your statement prior to going into the witness box, and should take a copy of that statement with you. If you want to refer to that statement because you cannot remember something, or because you know there is a fuller or better account in your statement, then you should ask the coroner if you can refer to your statement — the answer will always be “yes”. If, after reviewing your statement, you are still unsure, “I cannot recall” is an acceptable answer. You could also respond by saying “I do not recall this particular incident but my usual practice would be…”. It is vital not to speculate or provide answers to questions that are not within your area of knowledge or expertise.

Does everybody have independent legal representation?

Not all of the interested persons who are party to an inquest will have legal representation in the form of a solicitor or barrister. In some cases, for example, the family of the deceased may represent themselves.

Can I be found guilty or innocent at an inquest?

No. You are not on trial. In fact, the law was changed in 2009 to make ‘conclusion’ the word associated with the outcome of an inquest. This was precisely because the word ‘verdict’, which was previously used, was associated with criminal or civil trials. By law, The Coroner’s Court is not permitted to give a conclusion that appears to determine criminal or civil liability on the part of a named person.

What happens after the inquest?

The coroner will consider the evidence before providing a conclusion outlining the answers to the four statutory questions ‘who’, ‘when’, ‘where’, and ‘how’. A final death certificate will be issued to the family and the death registered. If the coroner takes the view there is a risk that future deaths might occur unless preventative action is taken, they will write a report which will be sent to the relevant authority. The relevant authority must reply within 56 days.