Understanding Coroner’s Inquests: A Comprehensive Guide

Losing a loved one is always difficult, but when a death is sudden, unexplained, or occurs under unusual circumstances, the process of understanding what happened can be overwhelming. A coroner’s inquest is a legal investigation which aims to establish the facts surrounding a person’s death, providing clarity and, where possible, peace of mind to the family. An inquest might take place if someone dies in a fatal accident at work, following a serious road traffic accident or in cases of suspected medical negligence.

If there is an inquest into a family member’s death, it’s natural to feel a mix of emotions. Knowing what to expect at a coroner’s inquest can help ease some of these concerns. This guide aims to provide an outline of the coroner’s inquest process, helping you gain understanding and answer any questions you might have.

What is a coroner’s inquest?

A coroner’s inquest is an official investigation into a death which is carried out if the death occurred under some specific outlined circumstances. A coroner’s inquest is legally required if:

● A person’s cause of death remains unknown after a post-mortem
● A person experienced a violent or unnatural death
● A person died in prison or police custody

The purpose of an inquest is to determine the cause of a person’s death, rather than attributing blame or liability. An inquest will explore the who, when, where and how of an unexplained death.

Key participants in a coroner’s inquest

There will be several people involved in the inquest process. Here, we outline who they are and the role they each play.

The Coroner

It is the coroner’s role to oversee the inquest. They will determine who should give evidence and will question any witnesses to establish the facts surrounding the person’s death.

At the end of the inquest, it will be the coroner’s responsibility to deliver the conclusion, giving information on how the person’s death came about.

The Family

During the coroner’s inquest process, close relatives or personal representatives of the deceased are considered ‘interested persons’.
An interested person has certain rights during an inquest, including the right to legal representation and being allowed to ask questions of witnesses during the inquest hearing. Family members may be asked to give evidence during the inquest hearing.

We cover the rights of interested persons and their roles in more detail later in this guide.

Witnesses

During an inquest, witnesses will be called on by the coroner to give evidence. They may also be required to answer questions. Witnesses will be required to take an oath or affirmation, stating that the evidence they’ll give is true.

Legal Representatives

As mentioned previously, an ‘interested person’ has the right to legal representation. Other participants in the inquest process may also have legal representatives present.

While family members aren’t required to have a lawyer at a coroner’s inquest, in more complex cases, they may choose to have the support of a legal team to help them navigate the process and to ensure that all circumstances surrounding the death are thoroughly investigated.

Medical Experts

In a coroner’s inquest, a medical professional may participate as either a professional witness or an expert witness.
A professional witness (or witness of fact) will usually have been directly involved in the management of the patient whose death is being investigated. The witness should present professional evidence detailing their clinical findings, observations, and actions.

An expert witness assists by providing information on areas that are outside the expertise of the court. It is unlikely that the expert witness will have been involved with the patient’s care, and if they have, they will need to declare a conflict of interest.

Jury

Most inquests won’t involve a jury but in some cases a jury is required. As outlined in Section 7 of the Coroners and Justice Act 2009, a jury is required if the senior coroner has reason to suspect that the person died while in custody or state detention and that either the death was violent or unnatural, or the cause of death is unknown.

Other circumstances where a jury may be required include when it’s suspected that the death is the result of an act of omission of a police officer or a member of a service police force, or in cases where the “death was caused by a notifiable accident, poisoning or disease.”

The coroner’s inquest process: What to expect

Here we explain what to expect at a coroner’s inquest:

Step 1: Opening of the inquest

If the coroner decides that an inquest is needed, they will open the inquest to issue a burial or cremation certificate, if this hasn’t already been provided following a post-mortem. The coroner will also hear evidence confirming the deceased’s identity. The inquest will then be adjourned and resumed at a later date.

The family don’t need to attend the opening of the inquest, but you should inform your solicitor or coroner’s office if you wish to attend.

Once the coroner’s investigations are complete, a date for the inquest hearing is given and the relevant people are informed. A coroner’s officer will be assigned to you. They can tell you what happens at an inquest and keep you up to date with the coroner’s inquest process.

If you have legal representation, your lawyer will be on hand to guide you through what can be a challenging time for the family. As part of their investigations, the coroner may ask family members to prepare a written statement. Again, this is something that your legal team can support you with.

Step 2: The inquest hearing

The inquest hearing will typically take place in a coroner’s court, and inquests are usually open to the public and media.

The coroner will lead the hearing; they will explain the purpose of the inquest and what is to be covered. Each witness will then be invited to give their statement or findings, and the coroner will ask any questions they have.

The coroner will then invite the family or other ‘interested persons’ and ask if they have any questions they’d like to ask. If you prefer, your legal team can ask questions on your behalf.

If written reports are used as evidence, relevant details will be read out. Before the coroner’s inquest concludes, legal representatives will be given the chance to address the coroner.

Step 3: The conclusion

Once all evidence has been heard, the coroner will make findings of fact based on the evidence and deliver their conclusion around how, when, and where the person died.

Legal rights during a coroner’s inquest

As mentioned earlier, close family members of the deceased may be given ‘interested person’ status. Interested persons have certain rights in the inquest process. These include:

• The right to view the body of the deceased and be given the details of any post-mortem examination that may take place.
• The right to receive information, documents, and evidence obtained by the coroner, including witness statements and expert reports that may be used during the inquest. This includes evidence provided by other interested parties (known as ‘disclosure’).
• You should be informed of the date of any hearings and have the right to attend both the inquest and any pre-inquest hearings.
• If requested by the coroner, you may provide a witness statement and give evidence at the inquest hearing.
• You have the right to question other witnesses at the inquest hearing, should you wish to do so.

Having the support of a specialist solicitor can help ensure your legal rights are protected during the coroner’s inquest process. If an inquest is required during the course of your legal claim, we will of course support you during this process.

How to prepare for a coroner’s inquest

Understanding what happens at an inquest can be beneficial for the family. Below, we outline some of the ways you can prepare for a coroner’s inquest.

Reviewing information

As an interested person, you can choose to have access to witness statements, expert reports and other documents as part of the coroner’s inquest process. You may wish to review this information prior to the hearing.

Giving evidence

You may be required to provide a written statement or give evidence if you can give information about the death or the person who has died. If you decide to use a lawyer, they can help you prepare for this and support with your written statement.

Preparing questions

You will be given the opportunity to ask questions of witnesses during the inquest hearing, so you’ll need to spend some time thinking about who you would like to question and what you’d like to ask.

Deciding on legal representation

In complex cases where there is suspected medical negligence or the death occurred following an accident at work or road traffic accident, many families choose to have the support and guidance of a specialist legal team – both in outlining a potential personal injury or medical negligence case, and in investigating the death as part of this claim.

Your lawyer can provide expert advice, as well as helping to ease the practical and emotional pressures that an inquest can have on the family. They can help prepare statements and can question witnesses on the family’s behalf, helping to uncover important details about the circumstances of your loved one’s death. They will also provide crucial support, ensuring that your rights are fully upheld, and your concerns are listened to.

Emotional preparation

As well as considering the practical preparations, it’s important to consider the emotional impact that the coroner’s inquest process can have. The coroner’s office, as well as your legal team, can help prepare you for what to expect. They can give you information on who will be attending the hearing and may be able to prepare you for any potentially distressing details.

If you decide to attend the inquest, you can bring a friend, family member, or someone from your community to provide you with support.

The emotional aspects of attending a coroner’s inquest

An inquest into a loved one’s death can be extremely emotionally challenging for the family, and understandably, it can be very difficult for family members to go over details of a loved one’s death. If you’ve lost a loved one unexpectedly, Fletchers Solicitors can provide compassionate legal guidance during this difficult time.

During the process, it’s normal for family members to experience a range of emotions including grief, confusion and frustration. It’s important that you reach out for support if you need it. The NHS has some helpful information on the support available after a bereavement.

Other organisations that can provide support are listed below:

Bereavement Advice Service
https://www.bereavementadvice.org/

Cruse Bereavement Care
https://www.cruse.org.uk/

The Samaritans
https://www.samaritans.org/

Coroner’s inquest findings and conclusions

The coroner will end the inquest by giving their conclusions. There are several types of conclusions that could be made at a coroner’s inquest. These include:

• accidental death or misadventure
• neglect
• industrial disease
• lawful/unlawful killing – the meaning of these terms is set out in law
• natural causes
• open, this is used when there is not enough evidence to decide any of the other conclusions
• road traffic collision
• stillbirth
• suicide

(Source: A Guide to Coroner Services for Bereaved People)

In some circumstances, the coroner may provide a narrative conclusion, offering a more detailed account of the circumstances surrounding the death and the reasoning behind the decision.

Although a coroner’s inquest is not about apportioning blame, the evidence that arises from an inquest may be relevant to any subsequent criminal or civil claims. If it is found that the negligence of someone else has contributed to your loved one’s death, whether that’s due to a fatal accident at work, or suspected medical negligence, you may be able to pursue a claim.

How Fletchers Solicitors can help you during a coroner’s inquest

Fletchers Solicitors can provide expert support during an inquest, by offering specialist legal representation, ensuring your family’s interests are properly advocated for throughout the entire coroner’s inquest process. Having specialist legal support can help ensure that no stone is left unturned and can help you get the answers you deserve.

We will help you understand your rights and options, guiding you through the often-complex legal aspects of the inquest process. Your dedicated solicitor will be on hand every step of the way, to answer any questions and address any concerns you might have.

Having supported families through the inquest process, we understand the sensitive nature of the situation and can help you access further support should you need it. Our expertise ensures that families are fully informed and supported throughout what can be a very difficult time.

If you’ve lost a loved one unexpectedly due to a fatal accident or medical negligence, our team of friendly and approachable solicitors are on hand to listen. You can call us for free advice on 0330 175 7651 or contact us online.

There are ways to challenge the coroner’s decision in certain circumstances; this will typically involve making an application to the High Court to seek a ‘judicial review.’

Our specialist solicitors have extensive experience with wrongful death claims, and can help you seek justice.