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Ranked as leading ‘Band One’ firm in the Chambers legal directory, Hickman & Rose is one the UK’s foremost law firms working in inquest law.
Lead by Daniel Machover, the team has acted for individuals and organisations caught up in many of the most significant inquest matters of the past two decades.
Below, Hickman & Rose’s expert inquest solicitors answer the following frequently asked questions about inquests and coronial law.
An inquest is a fact-finding investigation into a person’s death. Overseen by a coroner, an inquest aims to answer certain questions about a death.
The core purpose of an inquest is to answer the following four basic questions:
Inquests are an inquisitorial process, governed by coronial law, which is distinct from the adversarial processes in criminal law and civil litigation.
Inquests cannot assign blame or attribute liability. However, they can be important legal stepping stones to doing both these things.
Not every death needs investigation and an inquest is required in a limited number of circumstances. Inquests are most commonly held when a coroner has reason to believe that a death was one or more of the following:
An inquest is also required whenever someone dies in state custody, for example in prison, in a secure mental health unit, or in police custody.
A coroner is an independent, specially trained judicial officer who oversees the inquest process.
Since July 2013, all newly appointed coroners must be qualified lawyers, but coroners appointed before then can be lawyers and/or doctors. England and Wales are divided into around 70–80 coroner areas (the exact number changes over time due to mergers), each of which is headed by a Senior Coroner.
Most deaths in a Senior Coroner’s area are dealt with exclusively by the local Medical Examiner and the Registrar of Births and Deaths. In all other cases, the relevant coroner’s first duty is to decide whether it merits investigation, which is not necessary if the cause of a natural death is quickly established and there is no suggestion of human error contributing to the death.
Once a coroner begins investigating a death, unless the power of discontinuance arises (i.e. the cause of death becomes clear and is not violent or unnatural), the investigation must proceed to an inquest. In cases where an inquest is necessary, the coroner oversees the inquest process.
Coroners have wide-ranging powers and a great deal of discretion about how their powers are applied. One result of this is that not all coroners always apply coronial law in the same way.
No. An inquest is not the same as a criminal or civil trial. The main reason for this is that an inquest is inquisitorial rather than adversarial.
There is no “prosecution” nor any “defence” in inquest proceedings. They are not about establishing blame and so they do not involve opposing parties, as other legal proceedings do. Instead, inquests involve ‘Interested Persons’ who are legally defined in section 47 of the Coroners and Justice Act 2009.
Unlike criminal trials and civil trials, an inquest does not determine liability for a death. Having said this, an inquest’s conclusion can be a tremendously important step to achieving both these things.
An inquest hearing takes place in a Coroner’s Court. The court itself can vary in style, from a traditional courtroom to a more ordinary meeting room.
Generally speaking, the coroner sits behind a desk at the front of the room, with the various Interested Persons or their legal representatives sitting behind their own desks facing the front. A part of the room will be set aside for the witnesses to give their evidence and there will also be an electronic screen for witnesses or other participants to attend the hearing remotely, with prior permission.
Not all such rooms have space for a jury, but where an inquest is being heard by a jury, a section of the room will be set aside for the (maximum) 11 members of the jury to hear the evidence. There are usually seats in the court for the public, and any members of the media.
Coroners do not wear wigs or robes. Normally they wear a suit.
The inquest format is quite flexible. Precisely how an inquest hearing runs depends on various factors, and is decided by the coroner.
Usually, coroners gather the evidence they or an inquest jury require by asking questions of witnesses. These witnesses may be lay people (such as people who saw the incident in which someone died), or they could be expert witnesses, such as pathologists.
Where the evidence is uncontroversial, a witness may give their evidence in writing, in which case a written witness statement is read into the court record. Most key witnesses give evidence in person, when they can be questioned by the coroner and Interested Persons (or their legal representatives).
After hearing all the evidence, the coroner (or, if there is one, the jury) will come to a formal decision on the four questions each inquest must answer, which are set out in a Record of Inquest This decision or determination is no longer called a ‘verdict’ but is referred to as a “conclusion” or an “outcome”.
Inquests are public hearings which anyone can attend. This means that in addition to the coroner, the court staff, the family of the deceased and anyone directly impacted or professionally involved in a death, members of the public and the media can also attend an inquest hearing.
Coroners have the power to restrict public access in some exceptional circumstances, such as if they believe the evidence will be particularly sensitive or may adversely impact a young person.
They can also restrict the media from reporting certain facts of an inquest, although this power is not absolute.
While anyone can attend an inquest, there are restrictions as to those who are permitted to take an active part in proceedings.
In addition to the coroner, their staff, and members of a jury (if there is one),those with the following roles are permitted to participate:
An Interested Person at an inquest is an individual or organisation who falls within section 47 of the Coroners and Justice Act 2009. This includes anyone deemed by the coroner to have a particular interest in the death.
The coroner will always grant Interested Person status to:
Any Interested Person to an inquest has the right to:
Interested Persons have right to appoint legal representatives to act on their behalf.
Anyone not invited by the coroner to be an Interested Person may be able to make legal representations to become one.
Yes. Bereaved close family members are always granted Interested Person status at an inquest.
A family can exercise its rights as an Interested Person itself if it does not have legal representation. However, if the family has appointed a lawyer, they can do the above on the family’s behalf.
There is no requirement to have a lawyer at an inquest. However, inquests are formal legal processes with hard-to-understand rules. They can also have highly significant consequences.
Depending on the circumstances of the death and the inquest itself, it may be of significant assistance to engage a lawyer. Among the many ways in which a specialist inquest lawyer can help an Interested Person navigate the inquest process are:
Sometimes, but not usually. While most inquests are decided by a coroner sitting alone there are circumstances which a jury must be called in to reach the conclusions as to a death.
Juries must be summoned in cases where the coroner suspects one or more of the following:
Juries can be called in other inquests too. A coroner can summon a jury in any case where they think there is ‘a sufficient reason for doing so’. One potentially relevant consideration here may be the wishes of the family of the deceased.
Inquest juries have the right to ask questions of witnesses and are often encouraged to do so by coroners. Article 2 inquests very often have juries.
An Article 2 inquest (sometimes called a ‘Middleton inquest’) takes place in cases where an arm of the State is involved in a death.
Named after Article 2 of the European Convention on Human Rights (which obliges a State to protect the right to life and prohibits the intentional deprivation of life).
Article 2 inquests differ from other inquests in that the question “how did they come by their death?” is expanded to be “by what means and in what circumstances did the person die”? The consequences of this broader question can be profound. Because of this, Article 2 inquests are commonly described as “enhanced” inquests.
The following types of death will commonly result in an Article 2 inquest:
Sometimes several state bodies and/or individuals will be involved in an Article 2 inquest. Each of these will normally be separately legally represented.
Anyone involved in an Article 2 inquest is strongly advised to obtain legal representation in order to protect their rights and ensure the inquest process works for them. Unlike other inquests, public funding (Legal Aid) is generally available to pay for the legal representation of bereaved families in Article 2 inquests.
The length of any inquest can vary considerably. Some inquest hearings last just a few minutes. Others can last for weeks, or even months.
Longer inquests hearings are frequently the case when the circumstances of a death are disputed, or when the medical evidence is particularly complex.
No inquest can start until at least six weeks after a death. It is often the case that an inquest opens and then is immediately put on pause while the coroner commissions new evidence.
Even in the most straightforward inquest matters, it can take more than six months after a death for the inquest to conclude. The more complex the case, the longer the inquest proceedings take. Unfortunately, in some cases, it can be years after the death before the full inquest hearing takes place and conclusions are reached.
Pre-inquest review hearings are preparatory hearings that take place before the full inquest hearing. They enable Interested Persons to address the coroner on various elements of the inquest, and potentially influence the evidence heard and the inquest outcome.
Having heard submissions, the coroner makes decisions on various matters, including what documentary and witness evidence should be obtained and by when; the scope if the inquest, whether it is an ‘Article 2 inquest’; how long the final inquest will take; when it will take place; and various other practical and logistical arrangements
Pre-inquest review hearings can be held either in person at the coroner’s court, or online
At the end of the inquest the coroner (or if there is one, the jury) must reach a conclusion about the death under investigation and set out the determination in a Record of Inquest.
Previously known as “verdicts”, inquest conclusions can be pithy one- or two-word phrases (i.e. short form conclusions). Alternatively (or in addition) they can take a longer so-called “narrative” format.
Short-form inquest conclusions include ‘accident’, ‘suicide’, ‘unlawful killing’, ‘lawful killing’ or ‘natural causes’. There is also the possibility an additional ‘rider’ conclusion of ‘neglect’ in certain circumstances (although for the most part this is adjectival to the primary conclusion, for example, ‘suicide contributed to by neglect’).
A narrative conclusion describes the circumstances of a death in more detail. It may set out factors which, based on the evidence heard, caused or contributed to the death.
Whatever the conclusion, no inquest can find any named person or organisation has criminal or civil liability for a death.
In addition to the conclusion, an inquest can also result in a coroner being required to issue a Prevention of Future Deaths Report (PFD Report). A PFD Report is a formal document which requires the recipient to consider taking suitable action to prevent similar deaths in future.
PFD Reports should set out any circumstances that the coroner has identified which, in their opinion, create the risk of future deaths. These do not need to be circumstances which caused the death in question. .
While PFD Reports – which are public documents – are designed to prevent future deaths, rather than punish past failings, they can be deeply critical of their recipients.
The recipient of any coroner’s PFD Report is obliged to formally respond within 56 days. Responses – which are also public documents – must list the actions already taken or which it is proposed be taken and set out a timetable for actions to come, or provide an explanation as to why no action is proposed.
The Chief Coroner publishes all PFD reports and their responses, as well as an updated list of all PFD reports where the recipient has failed to respond within 56 days, until the response is received.
An inquest is not a criminal trial and cannot determine liability for any death. However, there are various ways in which the inquest process can lead to people, or organisations, being subject to criminal investigation and potentially held criminally accountable for their actions.
There have been numerous cases where a police force and/or the CPS has opened (or re-opened) a criminal investigation into a suspicious death following an inquest.
They may do this for one, or more of the following reasons:
An inquest is not a civil trial and cannot determine liability of a named person or organisation for any death. However, an inquest can be a vital stepping stone for establishing civil liability.
One way an inquest can help in this regard is in obtaining and testing evidence – both documentary and witness evidence – which may form part of a civil case. Another is by pressuring an Interested Person to make admissions of responsibility for a death or civil liability being admitted or otherwise leading to settlements of civil claims without such formal admissions.
After inquests, it is certainly not unusual for Interested Persons to formally accept the failings set out in a narrative conclusion and make formal apologies. Inquests can therefore be vital in helping bereaved families to secure official apologies and, in certain circumstances, compensation and damages.
An inquest is a public forum which the media has the right to attend, and to report on. They can report anything said in court. They can request access to documentary evidence to the inquest. If the coroner grants access to this documentation, they can report on its content.
Coroners do have some rights to impose restrictions on what the media report, but this is open to challenge Interested Persons can make representations to the coroner on material they feel should not be made public.
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