January 15, 2024

When should a coroner hold an inquest into a death?

What is an inquest?

Put simply, an inquest is an investigation to seek out and record the facts concerning a death. The coroner’s investigation often begins very shortly after the death once it has been referred to their office. The coroner will first consider whether a post mortem is necessary.

The purpose of an investigation into a person’s death, as set out in the coroner’s and Justice Act (CJA) 2009, is to ascertain:

  • Who the deceased was
  • Where the deceased came by his or her death
  • When the deceased came by his or her death
  • How the deceased came by his or her death.

In most cases the most difficult question is to determine how the deceased came by their death. In certain types of inquest, known as ‘Article 2 inquests, there is a greater obligation on the coroner to explore this particular question more fully but this is a complex topic in its own right.

An inquest is held by a coroner in a coroner’s court which is distinct from a civil or criminal court. An inquest is not designed to attribute blame for injury and death on specific individuals, unlike in civil proceedings. In fact, section 10 (2) of the CJA 2009 specifically prevents an inquest from establishing criminal or civil liability for a death or informing the basis for any criminal charges.

When should a coroner hold an inquest?

A coroner must conduct an investigation into a person’s death if he or she has reason to suspect that:

a) The deceased died a violent or unnatural death,
b) The cause of death is unknown, or
c) The deceased died while in custody or otherwise in state detention.

Any one of these three criteria is sufficient to require an investigation.

Violent or unnatural deaths

Violent deaths are normally easily identified. However, historically, there has been debate as to what constitutes an ‘unnatural death’ in this sense. It now appears that the threshold of an unnatural death is met if an unexpected death, albeit from natural causes, results from some culpable human failure. Additionally, an unnatural death may be identified if the death was contributed to by neglect. The rationale behind this category is that an unnatural death prompts understandable public concern as it is a vital part of the coroner’s role to investigate and allay such concerns.

Deaths where the cause is unknown

Where there is no proper certification of a cause of death, for example with a doctor’s certificate, then an inquest ought to be opened by the coroner. The fact that the family, for example, are sure of the cause of death is not normally adequate. Legislation requires that the cause of death is identified in every uncertified death.

Deaths in custody or other form of state detention

Section 1(2)(b) CJA 2009 requires that an inquest takes place when the death occurred in state custody or otherwise in state detention.

This includes anyone detained compulsorily by a public authority, for example, in prison, police custody, immigration detention centre or detained under mental health legislation.

For obvious reasons, there is a strong public interest in the thorough investigation of deaths which occur in custody as the deceased was under the control and responsibility of the authorities at the time the death occurred, and as it usually happens behind closed doors.

The inquest process and timescale

Once the coroner is alerted to the death which he or she should investigate, the coroner will undertake a number of preliminary duties, including holding a very short hearing in order to formally open the investigation. A coroner must open an inquest as soon as reasonably practicable and must also set down dates for any subsequent hearing as soon as possible.

Once formally opened, it could be a number of months or even years until the actual inquest hearing itself takes place where witnesses may be called to give evidence and, ultimately, the conclusion (previously known as the ‘verdict’) is determined.

There is an obligation on coroners to progress matters quickly. Any inquest which is not concluded within one year is notified to the Chief Coroner of England and Wales. Typically, timescales vary greatly depending on the resources available in that particular coroner’s court, the complexity of the case, the number of likely witnesses and/or the volume of evidence involved.

I will provide more information on pre-inquest review hearings and inquest hearings in a separate blog. However, if you have any questions or are concerned about the circumstances of the death of a loved one then please feel free to contact me for further advice.

Writing a statement for the coroner?

Read our guide on what you might need to consider when writing a statement for the coroner.

Read about how to write a statement here