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.
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.
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.
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’.
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.
A witness who must attend the inquest and give evidence in person.
Previously known as a verdict, this is the formal outcome of the Inquest. Examples of conclusions include natural causes, accidental death and suicide
An official who holds the inquest, similar to a judge in court. They also order the post-mortem examination.
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.
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.
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.
The review of the applicant’s financial resources undertaken by the Legal Aid Agency when deciding whether to grant funding.
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.
A “Middleton Inquest” is another name for an Article II inquest which you can read about above.
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
Used where no conclusion can be reached based on the evidence presented.
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.
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.
There are a range of short form conclusions available to the coroner, including but not limited to: suicide, industrial disease, misadventure and natural causes.
See Conclusion definition above.