Coronial law and inquests solicitors

An inquest is a fact-finding investigation, led by a Coroner, to establish answers to four statutory questions: who has died, when they died, where they died and how they came by their death. The question of how includes determination of the medical cause of a person’s death. An inquest is not a trial. It does not decide blame or liability. Instead, the purpose of an inquest is to establish facts and, where relevant, identify learning for the future.

An inquest is held when a death is violent or unnatural, the cause of death is unknown, or when the death occurred in custody or state detention. State detention can include prisons, police custody and, in certain circumstances, where persons are detained in accordance with the Mental Health Act.

At an inquest, the Coroner will consider evidence from relevant witnesses, either by reading witness statements or calling witnesses to be questioned in person. The Coroner can also consider relevant documents such as medical records, investigation reports, policies and procedures and in certain cases expert reports, for example.

Certain categories of person/organisation can be assigned Interested Person status at an inquest. This can include families, individuals, organisations, and public bodies. Interested Persons can also ask questions of witnesses and will be invited to do so by the Coroner once they have asked all of their questions. Once the Coroner has had an opportunity to consider all of the evidence, they will then confirm their determinations with respect to the four statutory questions and complete a document called the Record of Inquest.

How long an inquest lasts can vary significantly and depends on a number of factors such as its complexity, the number of witnesses, and whether the Coroner is sitting with a jury. Some straightforward inquests can take less than an hour, whereas more complex inquests can last several days or even several weeks. The longest inquest held was the inquests into the people who tragically lost their lives at the Hillsborough disaster, which lasted for over two years.

The coroner will ask questions of each witness first. The Coroner’s questions will be directed at answering the four statutory questions. The Coroner’s questions can include exploration of the events leading up to the death, the care or treatment provided, relevant decision-making and whether any wider concerns arise.

It is common for questions to focus on what actions particular witnesses took or didn’t take and why, and/or on any applicable policies, procedures, or other frameworks that were in place at the death. Questions are generally focused and evidence-based, but they can be detailed.

Interested Persons, or their legal representatives, often ask questions after the Coroner has asked all their questions. Again, these questions should also be directed at assisting the Coroner to answer the four statutory questions.

No. An inquest is a fact-finding investigation and the Coroner is not permitted to apportion blame to any organisation or named individual; that is simply not the purpose of an inquest. A Coroner is also strictly prohibited from making any findings that may appear to determine any question of civil or criminal liability on the part of a named person.

The Coroner has a duty in law to consider whether evidence gathered during the course of their investigation reveals that there is a risk of future deaths occurring if action is not taken. This duty is discharged by the Coroner writing a Prevention of Future Deaths Report, often called a Regulation 28 Report, to a person or organisation who the Coroner considers has the power to take action to prevent the risk of future deaths occurring. The recipient of any such Report has a corresponding duty to respond to the Coroner within 56 days of receipt of the Report.

A Coroner can call evidence from a multitude of different individuals or organisations, depending on the specific circumstances surrounding a death. For example, family members, doctors, police officers, paramedics, mental health professionals, witnesses to a traffic accident, employers, etc.

Article 2 of the European Convention of Human Rights (ECHR) protects the right to life and prohibits deprivation of life except in certain circumstances. Article 2 of the ECHR can be engaged at an inquest where certain specific circumstances arise. Where Article 2 ECHR is determined to be engaged, the Coroner’s scope (i.e. the matters they will seek to investigate) is widened, meaning the Coroner is more likely to look in more detail at the wider circumstances surrounding a death.

Weightmans have dealt with Article 2 inquests on a daily basis, including cases which have been heard at the appellate courts, and are well equipped to advise you about this complex area of law.

Not always. Often, Interested Persons do not require legal representation at an inquest, but this is very much dependant on the circumstances surrounding the death. If there is any cause for concern that the conduct of an individual or organisation may have contributed to the death, or more simply that there are concerns regarding the individual or organisation's involvement in the circumstances leading up to a death, it may be beneficial to seek legal representation.

Weightmans regularly helps clients navigate this decision and has developed tools to assist with making the right decision on whether representation is required.