Inquests and inquiries – what are they, and what are the differences in these inquisitorial processes?

In recent years, the number of public inquiries in the U.K. has increased significantly.  Several high-profile scandals have generated significant public interest in an independent investigation to provide answers and accountability. With the increase in inquiries, there is an inevitable overlap with the coroner’s duty to investigate deaths. 

It poses important questions around these two types of inquisitorial legal processes. How do they differ, and importantly, what binds the processes together? We will explore inquests, better understand inquiries, and then compare some of their key features. 

What is an inquest?

An inquest is a fact-finding process that investigating deaths, conducted by and presided over by a coroner. Not every death requires an inquest. An inquest is held in circumstances where there is a suspicion that death was unnatural, or when the cause of death is still uncertain after a postmortem, or if the person died whilst in state detention.  Some examples of unnatural deaths include an accident at work or road traffic collision. 

An inquest is tasked with answering four questions:

• who the deceased was;
• when the deceased died;
• where the deceased died; and
• how and by what means. 

Article 2 of the European Convention on Human Rights imposes, amongst other things, a positive obligation on the state to protect life. The positive duty includes the duty to properly investigate unnatural deaths. Where there is a suspicion that the state has failed to fulfil its Article 2 obligation, an inquest with a broader remit is required to fulfil the state’s investigative duty. Such Article 2 inquests examine the broader circumstances of the death, including any potential failings by state authorities to protect the individual’s right to life, and investigate by what circumstances the deceased died rather than just how they died.  

The coroner is prohibited from imposing any civil or criminal responsibility for the death. For example, there may be circumstances where an inquest occurs where someone was murdered, but it would not be the role of the coroner to determine criminal liability for the killing. 

Inquests are led by a coroner, who has the power to compel a witness to attend the inquest and request documents be produced. The coroner usually determines the outcome alone, but there are some circumstances where the coroner must sit with a jury. Those circumstances are where:

1. the deceased died a violent or unnatural death in custody or state detention;
2. the death resulted from an act or omission of a police officer or member of a service police force in the purported execution of their duty; or
3. the death was caused by a notifiable accident, poisoning or disease.

The coroner, or the jury when empanelled, will return a conclusion at the end of the inquest.  It can be a ‘short form’ conclusion e.g. unlawful killing, natural causes or road traffic collision. The conclusion can also take the form of a ‘narrative’ conclusion, which enables the coroner or jury to briefly explain the key facts leading to death. It is also possible for the conclusion to remain open if there is insufficient evidence.

There were 36,661 inquests opened in England and Wales in 2024, representing around 6.4% of total deaths. There have been many high-profile inquests. There was an inquest into the death of Princess Diana on 2 October 2007 that lasted for six months. The inquest included a jury and was led by coroner Lord Justice Baker.   Likewise, the terror attacks of 7 July 2005 resulted in a long inquest presided over by Heather Hallett as coroner in 2011. The longest inquest to take place was the Hillsborough inquests, which ran for 2 years (2014-2016) and investigated the deaths of 96 people who died at Hillsborough football stadium on 15 April 1989. 

What is a public inquiry?

A public inquiry is a formal, independent investigation relating to a matter of serious public concern. Public inquiries are independent inquiries, typically implemented under a statutory regime, and instigated by the government. The sponsoring minister will commence the inquiry, set the terms of reference and appoint a Chair to conduct the inquiry. 

The appointed Chair will then investigate the matters of public concern, amass evidence, conduct hearings and call relevant witnesses. The Chair will then draft a report, which will be published and laid before Parliament, and will seek to answer the terms of reference.   The Chair typically seeks to answer what happened, where accountability lies for any failings and set out recommendations to ensure failures are not repeated in the future. 

Using Section 21 of the Inquiries Act 2005, the Chair has powers to issue a notice to compel witnesses to disclose relevant documents and give oral evidence or a witness statement. Furthermore, under Section 35 of the same Act, a failure to comply with a Section 21 notice without reasonable excuse is a criminal offence punishable by a fine or up to 51 weeks’ imprisonment. These are key powers of a statutory public inquiry.

Statutory public inquiries seek to remain as transparent as possible. Indeed, Section 18 of the Inquiries Act 2005 requires a Chair to take reasonable steps to ensure there is public access to inquiry proceedings and information. Members of the public may be allowed to attend the inquiry with prior permission, some parts of the inquiry may be live streamed for the public to view, and relevant documents may be published on the inquiry website.

Public inquiries, by their very nature, are high profile. Recent examples include the Grenfell Tower Inquiry, the Infected Blood Inquiry and the Manchester Arena Inquiry.  Inquiries can also be every long running, such as the Bloody Sunday Inquiry, which lasted ten years, and the Independent Inquiry into Child Sexual Abuse, which lasted eight years. 

When inquiries and inquests will not overlap 

By its very nature, an inquest must involve a death; an inquiry does not have to. Many recent high-profile inquiries have investigated issues that did not solely involve deaths. For example, the Leveson Inquiry related to the phone hacking scandal and practices of the British press. The Post Office Inquiry investigated the failings of the Horizon IT system at the Post Office which as a result led to the suspensions, prosecutions and convictions of sub postmasters. The Infected Blood Inquiry examined why people in the UK were given infected blood and/or infected blood products.

Inquests or inquiries – when each process is used 

There is a natural overlap to inquests and inquiries – inquests always and inquiries sometimes investigate the tragic loss of life. Where there has a been a disaster or tragedy, there is both an obligation and a public concern requiring the investigating of matters to understand how life was lost. We need to, therefore, look at why one process might be chosen over the other. 

Inquests have a clearly defined scope in statute – they are required to answer the four statutory questions outlined above. Inquiries have the ability to consider a far broader scope and can consider a wider range of evidence, and so they are generally much longer and more detailed than an inquest. This is why Grenfell Tower was constituted as an inquiry from the outset – there was a strong public desire for a wider investigation than an inquest.  

As a general principle, inquiries are more detailed investigations than inquests. The Court of Appeal in R (Morahan) v HM Assistant Coroner for West London [2022] EWCA Civ 1410 helped explain the difference in approach between the two:

“An inquest remains an inquisitorial and relatively summary process. It is not a surrogate public inquiry. The range of coroners’ cases that have come before the High Court and Court of Appeal in recent years indicate that those features are being lost in some instances”

There are many high profile and complex inquests where a senior judge is appointed to act as coroner. Such examples are the Hillsborough inquests and the inquests relating to the terrorist attacks of 7 July 2005. Such inquests proceed under the statutory regime for inquests, but their high-profile nature and separately appointed coroners give the inquests a similar appearance and approach to a public inquiry, and at least test the distinction drawn the Court of Appeal above. 

Likewise, sometimes inquests have to convert to inquiries. This is because inquests can only have hearings in open courts. Where there is evidence impacting national security , inquests must convert to inquiries so that the inquiry can conduct closed hearings to deal with that evidence. This was most recently seen in the Manchester Arena Inquests, which converted to a statutory public inquiry in October 2019, with the same coroner becoming the Chair. Similarly, the Litvinenko Inquiry converted from an inquest, which was an inquiry into the 2006 murder of ex-Russian spy Alexander Litvinenko, that found that he died from acute radiation syndrome after drinking tea containing polonium-210.

Their shared commonality – the importance of learning 

Both inquests and inquiries hold a shared importance around learning from these tragic events. The learning is at the direction of the coroner for inquests and Chair for inquiries, both predominantly through written means. 

Inquest Coroners Prevention of Future Death’ (PFD) report

One of the most important roles of a coroner is their power under Paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009 to issue a ‘Prevention of Future Death’ (PFD) report.  A PFD report is directed to a person or organisation that the coroner considers that action should be taken by that organisation or person to prevent future deaths from occurring in similar circumstances. PFD reports might raise one particular issue, such as insufficiency of allergy information for ingredients in food products. 

Likewise, PFD reports may be very long documents setting out numerous issues of concerns for multiple organisations to take action in response. Sir Adrian Fulford, who was coroner of the inquest arising from the Forbury Gardens terror attack of 20 June 2020, produced a PFD report on 20 May 2024 that detailed the failures that contributed to the deaths. The report dealt with matters ranging from mental health care to the operation of the Government’s Prevent regime.

Inquiry Chair Recommendations

To a similar extent, a Chair will make recommendations in their final report. The difference being that coroners highlight concerns, but they cannot make recommendations, whereas Chairs can make specific recommendations. A Chair makes a recommendation for specific actions that relevant bodies should make in response to the failures identified during the inquiry. For example, during the Post Office Horizon Inquiry, a recommendation was made for urgent compensation to be given to the affected sub-postmasters.

It is important to note that neither PFD reports or recommendations are enforceable on those individuals or organisations they are directed to. There has been public discourse around plans to ensure that recommendations from public inquiries are acted on but this is yet to be seen.

What we can learn from understanding both processes

The key takeaway is how much binds inquests with inquiries, rather than what distinguishes them. The processes for both an inquest and inquiry are investigative and inquisitorial in nature, they are not adversarial like a typical court hearing, and there are no sides of ‘for and against’. The process in both is generally public and transparent, with access to most hearings and with most of the key reports published for wider consumption.

They both have special legal status for interested individuals and organisations, albeit with slightly different terminology used for each: ‘Core Participants’ in a public inquiry and ‘Interested Persons’ in an inquest. They are both driven with a determination to make recommendations for future prevention of deaths or wider learning, and those recommendations are not legally binding, even though their powers and ambit to do so are different. Critically, they both play a vital role and aim to aid understanding of events while also preventing future tragedy.

Inquests and inquiries are difficult, emotionally challenging legal processes, sometimes complex and long-lasting legal processes requiring careful navigation and expert legal support.