Inquests

1. The death is referred to the coroner.
2. The coroner asks a pathologist to carry out a post mortem to determine the cause of death.
3. The coroner determines that an inquest should be held and formally ‘open’ and adjourns the inquest proceedings while further investigations take place.
4. The coroner contacts all ‘interested persons’ to let them know an inquest is taking place.
5. The coroner’s office gathers any outstanding witness statements and further evidence needed by the coroner.
6. In more complex cases, or where an Article 2 Inquest may be necessary, a ‘Pre-Inquest Review Hearing’ (PIR) will be held. This will plan what further evidence is needed (including expert evidence), what steps will be taken to obtain this, and the timeline involved.
7. The inquest takes place. During the inquest the following takes place:
   • The witnesses give evidence (including any experts)
   • The coroner and interested persons/their legal representatives may ask the witnesses questions.
   • The coroner summarises the main points of the witness evidence
   • Legal representatives address the coroner on the possible conclusions permissible at law and the possible conclusions the coroner and jury could reach
   • The coroner (or jury), will give their conclusion, determining who, how, when and where the person died. For Article 2 Inquests, the coroner will also set out the relevant circumstances surrounding the death.
   • If applicable, the coroner will make a Regulation 28 (‘Prevention of Future Deaths’) Report. This involves writing to the body responsible to ask for changes to be made to prevent future deaths. The body will then have a legal duty to respond.
   • Sometimes, the coroner will arrange for a short delay between the inquest being heard and the conclusion being delivered.  This typically occurs where the witness and other evidence is complex and requires further consideration.

An ‘Article 2 Inquest’ refers to an inquest where Article 2 of the European Convention of Human Rights (ECHR) is engaged. This is a technical legal area but, Article 2 generally applies when it is suspected that a person died while ‘in the care of the state’. These inquests are often also referred to as ‘Middleton Inquests’

An Article 2 Inquest requires the coroner to undertake an enhanced investigation to examine the ‘broad circumstances’ of how a person arrived at their death. It may be required when a state body failed to provide adequate systems to prevent the death occurring and/or if a state body has been grossly negligent (to the extent it could be considered criminal), for example.

Those who the coroner considers ‘interested persons’ can participate in a coroner’s investigation. It can include:

• Spouse, civil partner, or partner.
• Parent, grandparent, stepfather, or stepmother.
• Child, grandchild, niece, or nephew.
• Brother, sister, half-brother, or half-sister.
• Personal representative of the deceased; and / or
• Person who may by any act or omission have caused or contributed to the death of the deceased, or whose employee or agent may have done so.

As an ‘interested person’ your rights include:

• Being notified of an inquest date within one week of the date being set.
• Receiving any document(s) held by the coroner that are requested (unless the request is considered by the coroner to be unreasonable or there is another lawful reason not to disclose).
• The authority to ask questions of any witness giving evidence in person at the inquest.
• To be legally represented at the inquest.

The Coroner’s Office (often a designated Coroner’s Officer) should keep you updated throughout the process and inform you about post-mortem arrangements. If you have instructed a solicitor, you can nominate them to receive these updates if you prefer.

Most coroners aim to complete inquests within six to nine months of the initial report of the death.  Where the circumstances are particularly complex or the coroner requires independent expert evidence, an inquest can take longer.

While the inquest is proceeding, the coroner will issue a Certificate of Fact of Death (often referred to as the ‘interim death certificate’) to enable you to notify others of your loved one’s death.

Most inquests are heard with only the coroner presiding.  Occasionally, a jury is also used.  Where a jury is used, they will be instructed to reach their conclusion or verdict on a ‘balance of probabilities’ (i.e. more likely than not) basis, unless being asked to decide on a conclusion of ‘unlawful killing’, for which the threshold is ‘beyond reasonable doubt’.

If you are an ‘interested person’ you can ask questions at the inquest.  This is usually done in person, but some coroners are happy to accept ‘written submissions’ (written questions or points). We recognise that this can be a daunting process and can arrange legal representation at the inquest instead.

Written witness statements are usually obtained at an early stage by either the Police or Coroner’s Officer.  Not all witnesses are called to give evidence in person.  The coroner will decide before the inquest whose statement should be read out loud (usually by the coroner or their officer) and who should be giving evidence in person at the inquest.  A statement read from paper is sometimes referred to as ‘Read under Rule 23’.

If the coroner plans to read the statement of a witness whom you would like to question, you can ask that they attend in person for this purpose.  It is up to the coroner whether your request can be agreed.

A Jamieson Inquest is an inquest where Article 2 is not engaged and the coroner is focussed solely on determining who died and when, where, and how they died.

An inquest is impartial and will not investigate liability or who is to blame for a person’s death. The coroner is not allowed to make any findings concerning civil or criminal liability but may make conclusions about what caused or contributed to your loved one’s death. The coroner’s findings may be helpful if you wish to make a compensation claim after the inquest.

Where a coroner feels the circumstances surrounding the death of your loved one give rise to the possibility of others dying in similar circumstances, they may formally write to the body responsible to ask for changes to be made to prevent future deaths. The body will then have a legal duty to respond.

Some examples are set out below.

1. Short-form conclusion
   • Suicide
   • Industrial disease
   • Misadventure
   • Natural causes
   • Want of attention at birth
   • Stillbirth
2. Narrative conclusion
3. Open (or no) conclusion
4. Unlawful killing

At the end of the inquest, the coroner will provide their inquest results by way of conclusion issue a final death certificate so that the death can then be officially registered.

The conclusion cannot (in most circumstances) include any suggestion of blame.  However, the findings can be relevant to compensation claims for medical negligence, personal injury, or industrial disease.

You may disagree with the coroner’s decision either not to hold an inquest or the conclusion of the inquest. You can only challenge this by making an application to the High Court, usually with ‘leave’ (permission) from the Attorney General.  Novum Law’s specialist inquest lawyers can provide you with further advice on this if required.