What you need to know when you're involved in an inquest

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An inquest is a formal investigation conducted by a coroner in order to determine how someone died. Inquests are held only in certain circumstances, such as where a death was sudden and the cause is unknown, where someone has died an unnatural or violent death, or where someone has died in a place or circumstance where there is legal requirement to hold an inquest, for example in prison custody or whilst sectioned under the Mental Health Act.

The purpose of an inquest is limited to establishing four key things: the identity of the deceased as well as where, when and how they died.

FAQs

What happens during an inquest following an unexpected death?

Save for the most straightforward inquests, the coroner’s investigation can take place over many months depending on the particular circumstances of the case and the complexities involved.

1 – The post mortem

At the outset of the investigation the coroner will usually arrange for a post mortem, sometimes known as an ‘autopsy’, to be performed. Following the examination, the pathologist prepares a report of their findings as to the cause of death.

2 – Pre-inquest review hearings

There may be a pre-inquest review (PIR) hearing in advance of the final inquest hearing. This is a hearing before the coroner where arrangements are made to prepare for the inquest hearing itself.

No evidence is heard at a PIR. Instead, it focuses on the practical steps that need to be taken in preparation for an inquest. This can include, for example, disclosure of documents, production of witness statements, deciding which witnesses would need to be called to give evidence, and trying to agree the likely date and length of the inquest hearing. In some inquests there could be several PIR hearings before the inquest itself takes place in order to ensure everything is in place for the final hearing.

What happens at a Pre-Inquest review hearing?

The PIR hearing focuses on practical matters and the steps required to prepare for the final hearing. The hearing will not address any of the evidence directly, and no witnesses or experts will be called to attend.

Whilst the specific issues will vary widely between cases, there are a number of areas which are likely to be considered at a PIR. For example:

  • the coroner can determine the scope of the inquest, such as the date range which will be considered and whether it will be an ‘ordinary’ inquest or whether Article 2 of the Human Rights Act will be engaged
  • whether appropriate documents and records have been disclosed to the coroner and the other interested parties
  • agreeing which witnesses ought to be called to give evidence in the inquest
  • whether the inquest will be heard with a jury present
  • whether there is a need for expert evidence and, if so, what specific type of expert will be required
  • practical arrangements such as the likely length of the inquest hearing and the likely date it will take place
  • whether there is a need for any further investigations and enquiries to be conducted before the inquest. For example, involving the police, CPS, Independent Police Complaints Commission, Health & Safety Executive, hospital trust or the Prisons & Probation Ombudsman.

Does the family need to attend?

It is always advisable to attend the pre-inquest review hearing so that you can participate fully in the preparations for the inquest.

A coroner may only have limited information about the death at the outset, so the PIR is a crucial opportunity to ensure the coroner is fully aware of the key issues and that he or she has all the relevant information to thoroughly explore the circumstances of the death.

If you have a solicitor or barrister representing you, they will be able to guide you through the process and will also make submissions to the coroner on your behalf. It is likely that the other interested parties will have legal representation in attendance on their behalf.

PIR hearings are vital to ensure appropriate steps are taken early on in the inquest investigation. With proper participation, the PIR maximises the likelihood of a full and thorough inquest hearing into the circumstances of the death. For this reason it is advisable to have specialist legal representation to attend the pre-inquest hearing on your behalf. They will offer invaluable support to guide you through the process and to share the burden when a loved one has died.

3 – The inquest hearing

The inquest hearing itself often represents the culmination of many months of work in collating relevant documents, statements and reports.

During the inquest hearing the coroner will call witnesses to give evidence. The coroner, and anyone else deemed to have a proper interest in the proceedings (known as an ‘interested person’), will then have the opportunity to ask questions of the witness. If the inquest is being heard with a jury, then the jurors will also be allowed an opportunity to ask further questions of each witness.

Sometimes a witness will not be called to attend the inquest in person but, instead, their statement will be read out in the hearing so that it still forms part of the evidence. This usually happens where their evidence is not controversial but where it is still deemed relevant to the coroner’s investigation.

Once all of the witnesses have been called, the coroner sums up the evidence heard. The coroner will give his/her conclusion (previously known as the ‘verdict’) and will also complete the Record of Inquest form to note the findings that were reached.

If there is a jury then it is the jury who will determine the conclusion at the end of the inquest. The coroner will give the jury guidance as to which conclusions they may reach (based on the evidence that has been heard) and will explain their obligations as a jury, before asking them to retire and consider their conclusion.

What are the rights of a bereaved person?

Broadly speaking, an ‘interested person’ is someone who has the right to actively participate in the inquest proceedings. This can be because of their relationship to the deceased, involvement in the circumstances of the death, or at the discretion of the coroner.

An ‘interested person’ is defined in the Coroners and Justice Act (CJA) 2009. Generally, there is unlikely to be any issue in the immediate family securing direct involvement in the inquest hearing, though problems can arise in certain situations. For example, where a family is divided and there is acrimony; where the deceased has no known family; or where the family have no interest in the inquest or are obstructive to it taking place.

These are significant rights conferred on interested persons during an inquest, with a view to them being able to participate fully in the process and to assist the coroner’s inquiry.

The key rights of the interested persons during an inquest include:

  • to be notified by the coroner about key aspects of post mortem or toxicology analysis;
  • to be provided with copies of relevant documents held by the coroner including that which the coroner considers relevant to the inquest;
  • to see written evidence and to object to it being used as evidence at the inquest hearing;
  • to question witnesses at the inquest hearing.

How can you fund an inquest?

If you require specialist legal representation in an inquest there are a number of options available to you in terms of funding. In some circumstances legal representation can be provided at no cost to the you, for example by way of Legal Aid public funding, or if you have legal expenses insurance in place.

Alternatively, representation can be funded privately, or with a ‘no win, no fee’ agreement. We will carefully consider all options available in your case and we will advise you on the best options for your particular circumstances.

Writing a statement for the coroner in an inquest

As a family member of someone who has died you may have been asked by a coroner, or a coroner’s officer, to provide a statement.

Even if you have not been asked, you may wish to give a statement so the coroner is aware of the concerns you have and questions you want answered by the inquest process.

Why have I been asked to write a statement for the coroner?

There are a number of reasons you may have been asked to write a statement for the coroner.

It may be very early on after a person has died and the coroner will be considering whether or not to hold an inquest. At this stage, they may ask the family of the person who has died to provide a statement if they have any concerns about how someone died. This is to give the coroner more information when deciding whether or not to hold an inquest.

If the coroner has already opened an inquest, they are likely to request a statement or information to understand what you or your family’s concerns are. It is also an opportunity to provide information about your loved one’s care that may not be apparent from the other evidence the coroner is gathering.

What do I write in a statement?

Your statement can cover whatever information you think the coroner should know when making their investigations into how your loved one died. However, it can be very helpful for the coroner to know:

1- who is writing the statement

Introduce yourself and explain how you are related to the person who has died.

If you are writing the statement on behalf of other family members or they have helped you write the statement, you can say this as well.

2- about the person who died

Often the coroner will only have basic information about your family member or what has been said about them in the other evidence, such as GP reports, medical records or prison records. Therefore, it can be important to write a paragraph about who they were, what their family was like, their personality and their hobbies.

3- what you remember about the circumstances of the death

How much you can write about the factual circumstances of someone’s death will differ from person to person depending on where and how someone died.

For example, if the person who died was in prison, you may only be able to talk about any communication you had with them by phone or when visiting. However, if they were in hospital or living at home, you may be able to give a detailed factual chronology as you remember it of the days, weeks or months leading up to the person’s death.

The best way to approach this bit of the statement is often chronologically, writing what you remember. If someone else has told you information you want to include, you can include this as well, but it is always best to say “I was told by……” so that it is clear the information you have got from someone else.

4- what your concerns are

An important part of the statement will be to set out the questions you or your family have about the death and any concerns about the treatment your loved one received prior to their death.

For example, you may be concerned that doctors did not diagnose sepsis quickly enough, observations were not being done regularly on a high-risk psychiatric patient, district nurses were not treating a pressure sore appropriately or that healthcare staff had not been checking an unwell prisoner.

Your questions and concerns can be very specific or very vague but it is important for the coroner to know what areas they may have to investigate during an inquest which were relevant to the death.

Explaining the legal jargon

If you’re considering an inquest into the death of someone close to you, or have read about the process, then you’ll know there’s a considerable amount of legal jargon that comes out of any proceedings.

Here we give you the top terms you might need to know, to help you when you’re involved in an inquest:

Article 2 inquest

This refers to Article 2 of the European Convention on Human Rights (commonly known as the ‘right to life’). If someone has died whilst under the care of the state – for example, in prison, police custody, or whilst sectioned under the Mental Health Act – or by agents of the state such as a police shooting or restraint then Article 2 will be engaged. This is because the State has a duty to take appropriate steps to safeguard the lives of people who are in its care.

In these inquests the coroner will not just look at ‘how’ the deceased died but also ‘by what means and in what circumstances’. This allows the coroner to look deeper at the context and background of the death than in a non-Article 2 inquest.

 

Balance of probabilities

When the coroner or jury is reaching a conclusion at an inquest or deciding what bits of evidence are true during the inquest, then they must come to these decisions ‘on the balance of probabilities’. This means they have to say that it is ‘more likely than not’ that an event occurred or that someone has died in a particular way.

The only conclusion for which this is different is the conclusion of ‘unlawful killing’. In order to reach this conclusion the coroner or jury must be sure ‘beyond reasonable doubt’.

Barrister

A type of lawyer, who is also known as Counsel, who can represent you at an inquest and ask questions on your behalf.

Beyond reasonable doubt

When the coroner or jury is reaching a conclusion at an inquest of ‘unlawful killing’ then they can only reach this decision if they are sure ‘beyond a reasonable doubt’. This means that they are sure that based on the facts of the case, there is no other logical version of events.

Called

A witness who must attend the inquest and give evidence in person.

Conclusion

Previously known as a verdict, this is the formal outcome of the Inquest. Examples of conclusions include natural causes, accidental death and suicide

Coroner

An official who holds the inquest, similar to a judge in court. They also order the post-mortem examination.

Coroner’s officer

Helps the coroner with the inquest process, such as corresponding with Interested Persons and managing the disclosure of information.

Exceptional Case Funding

A type of Legal Aid funding that helps cover the cost of representation by a solicitor and/or barrister at an inquest.

Inquest

A judicial inquiry held when there has been a sudden, unexplained, violent or unnatural death. The purpose is to determine how, where and when the death occurred.

Interested Person (IP)

Individuals and bodies with the right to ask questions at an inquest; as defined in the Coroners and Justice Act 2009. Family members i.e. parents and partners of the person who has died are automatically given Interested Person status but the definition can also include a hospital, care home, Council, trade union, police force and many other bodies, dependent upon the circumstances.

“Jamieson Inquest”

Sometimes an inquest will be referred to as a “Jamieson Inquest”. This simply means that Article 2 is not engaged in this inquest. This means the coroner will deal strictly with the four questions he or she has to answer: who the deceased was, where they died, when they died and how they died. In these inquests, the coroner will not look at the wider circumstances surrounding someone’s death.

Legal Aid funding that covers the cost of advice and assistance from a solicitor to help prepare for an inquest.

Means Test

The review of the applicant’s financial resources undertaken by the Legal Aid Agency when deciding whether to grant funding.

Merits Test

The review of the applicant’s case undertaken by the Legal Aid Agency when deciding whether to grant funding. The Legal Aid Agency will consider whether there is a risk of a breach of the Article 2 ‘right to life’ if funding is not granted. They will also look at whether there is a wider public interest in relation to the inquest, i.e. whether representation at the inquest would produce a significant benefit for a wider class of people other than the applicant and their family.

“Middleton Inquest”

A “Middleton Inquest” is another name for an Article II inquest which you can read about above.

Narrative conclusion

Conclusions (previously called verdicts) are the formal outcome of an inquest. A narrative conclusion is used where one of the ‘short form’ conclusions, such as suicide or natural causes, is not sufficient to fully explain how someone came by their death.

In a narrative conclusion the coroner, or the jury if there is one, will outline the circumstances of the deathin a short description to better explain what happened. Occasionally a questionnaire is produced for the jury to answer which will form the conclusion

Open conclusion

Used where no conclusion can be reached based on the evidence presented.

Post-mortem

A detailed examination of the body to determine the cause of death. Otherwise known as an autopsy.

Pre inquest review (PIR)

A hearing held with the coroner and Interested Persons to plan for the Inquest. PIRs typically address legal and procedure issues before the full inquest, including: obtaining relevant records and statements; which witnesses will attend the hearing; and confirming who the Interested Persons should be.

Prevention of Future Deaths (PFD) report

If the coroner becomes aware of something during the investigation which suggests other people are at risk of dying if changes aren’t made, then they have a duty to write to the appropriate authority, person or organisation, who has the power to make a change and recommend that they take action to prevent future deaths. This is sometimes known as a Regulation 28 Report.

Read (Rule 23)

The coroner may decide that a witness’s written statement can be read aloud in court and that the witness does not have to attend in person to answer questions. This usually happens when the evidence is not controversial or not challenged by any of the parties. Rule 23 of the Coroners (Inquests) Rules 2013 is the rule that allows this to happen.

Submissions

The statements or documents that your solicitor or barrister will make to the court on your behalf. i.e. your requests for how the hearing or evidence should be managed, or your suggestions as to the conclusions which could be reached.

Short-form conclusion

There are a range of short form conclusions available to the coroner, including but not limited to: suicide, industrial disease, misadventure and natural causes.

Verdict

See Conclusion definition above.

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