Preparing for a Pre-Inquest Review (PIR)

Introduction

A Pre-Inquest Review is a case-management hearing held before the final inquest.

It is often called a “PIR”. Its purpose is not to decide how someone died. Instead, the Coroner uses the hearing to identify the issues which need to be investigated and to make practical arrangements for the inquest.

Important decisions can be made at a PIR, including decisions about:

The scope of the inquest;
Which witnesses will give evidence;
What documents must be disclosed;
Whether expert evidence is required;
Whether Article 2 is engaged;
Whether the inquest will be heard with a jury; and
When and where the final hearing will take place.

For families, understanding these issues in advance can make the hearing more manageable and help ensure that their concerns are properly considered.

For a wider explanation of the coronial process, see What Happens at an Inquest? – A Step-by-Step Guide.

What Is a Pre-Inquest Review?

Under rule 6 of the Coroners (Inquests) Rules 2013, a Coroner may hold a Pre-Inquest Review at any time during the investigation and before the final inquest.

The Chief Coroner’s guidance on Pre-Inquest Review hearings describes a PIR as an administrative case-management hearing intended to ensure that the inquest is managed effectively, efficiently and openly.

A PIR is not the inquest itself. The Coroner will not ordinarily hear the full evidence, question the principal witnesses or reach a conclusion about the death.

Instead, the Coroner will decide how the investigation should proceed.

Will Every Inquest Have a Pre-Inquest Review?

No. Many straightforward inquests do not require a separate PIR.

Where the issues are limited and there is little disagreement about how the case should proceed, the Coroner may give directions in writing or deal with preliminary matters when the inquest is opened.

A PIR is more likely where:

The circumstances of the death are complicated;
Several organisations are involved;
There are disputes about the scope of the inquest;
A large volume of evidence must be considered;
Expert evidence may be required;
Article 2 may be engaged;
A jury may be required;
The inquest is expected to last several days; or
Interested Persons disagree about witnesses, documents or other procedural issues.

A complex inquest may require more than one PIR before it is ready for the final hearing.

Who Can Attend?

The Coroner will usually notify the Interested Persons of the hearing. This commonly includes the bereaved family and any person or organisation whose conduct may be examined during the inquest.

A family member who has been recognised as an Interested Person may attend, make representations and ask the Coroner to consider particular issues. A family represented by a Solicitor or Barrister will usually have those representations made on its behalf.

For an explanation of who can participate formally, see Interested Person Status in Inquests: What Families Need to Know.

Pre-Inquest Reviews are generally held in public. However, rule 11 of the Coroners (Inquests) Rules 2013 permits the Coroner to exclude the public from a PIR where this would be in the interests of justice or national security.

A PIR may take place in a courtroom, by video link or through a combination of in-person and remote attendance. The arrangements will depend upon the Coroner and the circumstances of the case.

What Will the Coroner Consider?

The Coroner will normally prepare an agenda identifying the matters to be discussed. The Interested Persons may be invited to provide written submissions or suggest additional agenda items before the hearing.

The principal issues commonly include the following.

The Scope of the Inquest

The scope determines which events and issues the Coroner will investigate.

For example, the Coroner may need to decide whether the inquest should consider only the immediate circumstances of the death or whether it should also examine earlier decisions, systems, policies or failures.

The scope is important because it affects which evidence will be obtained, which witnesses will be called and what questions may properly be asked at the final hearing.

A family should identify clearly any issue which it believes contributed to the death and explain why that issue requires investigation.

Interested Persons

The Coroner may consider which people or organisations should be formally recognised as Interested Persons.

This status carries important rights, including the right to receive relevant disclosure, ask relevant questions of witnesses and make submissions to the Coroner.

Article 2

In some cases, the Coroner will decide whether the enhanced investigative duty under Article 2 of the European Convention on Human Rights is engaged.

This can affect the scope of the inquest and the way in which the question of how the deceased came by their death is approached.

For further guidance, see What Does Article 2 Mean for My Family?

Whether a Jury Is Required

Most inquests are heard by a Coroner sitting alone. In certain circumstances, however, the law requires a jury.

The Coroner may use the PIR to decide whether the statutory test for a jury is met or whether there is otherwise a sufficient reason to summon one.

Witnesses

The Coroner will consider which witnesses should attend the final inquest to give oral evidence.

A family may ask the Coroner to call a particular witness, but the final decision belongs to the Coroner. It will usually be necessary to explain:

What relevant evidence the witness can provide;
Which issue that evidence addresses; and
Why a written statement would not be sufficient.

The Coroner may also decide that some evidence can be read or summarised without requiring the witness to attend.

Disclosure

Disclosure means the provision of documents and other evidence relevant to the inquest.

At the PIR, the Coroner may consider:

What evidence has already been obtained;
Whether further records are required;
Which organisations hold relevant material;
Whether any documents are missing;
When disclosure will be provided; and
Whether information must be redacted before it is released.

Families should review the documents they have received before the hearing and identify any obvious gaps.

Expert Evidence

Some inquests require independent expert evidence. This may include evidence from a medical specialist, pathologist, engineer or another appropriately qualified expert.

The Coroner may consider:

Whether an expert is necessary;
The expert’s area of expertise;
The questions the expert should be asked;
What evidence the expert should receive; and
When the report must be completed.

The fact that a family or another Interested Person would find an expert helpful does not necessarily mean that the Coroner must appoint one. The Coroner will consider whether expert evidence is required to investigate the death properly.

The Final Hearing

The PIR will often address practical arrangements, including:

The date and estimated length of the inquest;
The venue;
Whether any participants will attend remotely;
The order of witnesses;
Deadlines for evidence and written submissions; and
Any accessibility or special arrangements which may be required.

Families should raise any dates on which they or important witnesses cannot attend.

How Should a Family Prepare?

The family should begin by reading the PIR agenda and all available evidence.

It may be helpful to prepare a short list of the principal concerns which the family believes the inquest should investigate. Those concerns should be expressed as clearly and specifically as possible.

For example, rather than saying that the overall care was inadequate, the family might identify:

A delay in recognising a deterioration;
A failure to act upon test results;
A missed opportunity to obtain medical assistance;
Inadequate observation or supervision;
A failure to communicate important information; or
A particular policy or system which may not have been followed.

The family should also consider:

Whether relevant records appear to be missing;
Which witnesses may have important evidence;
Whether specialist expert evidence may be required;
Whether there are particular questions about Article 2 or a jury;
Whether the suggested hearing dates are workable; and
Whether any support or accessibility arrangements are needed.

A chronology can be particularly useful in a complex case. It does not need to contain every detail. Its purpose is to identify the principal events, decisions and concerns in date order.

What Happens at the Hearing?

The Coroner will usually work through the agenda one issue at a time.

Each Interested Person will have an opportunity to make relevant representations. The process is generally more conversational than the final inquest, although it remains a formal court hearing.

Family members should not feel that they must make legal submissions themselves. They can explain their concerns in ordinary language and ask the Coroner to clarify anything they do not understand.

The Coroner may make decisions immediately or reserve a particular issue until further information has been obtained. Directions will usually be recorded in writing after the hearing. Those directions may set deadlines for:

Providing statements or records;
Obtaining expert evidence;
Making further disclosure;
Filing written submissions; and
Preparing for the final inquest.

What If the Family Disagrees with a Decision?

A family can explain why it disagrees and ask the Coroner to reconsider the issue. It is usually important to identify the specific decision in question, the reason it matters and the evidence or legal principle said to support a different approach.

A decision made at a PIR is not necessarily irreversible. A Coroner may revisit a procedural decision before the inquest concludes, particularly where new evidence or a material change in circumstances arises.

However, significant disagreements about scope, witnesses, Article 2, expert evidence or a jury should be raised as early as possible. Waiting until the final hearing may make the issue more difficult to resolve fairly and efficiently.

Does a Family Need Legal Representation?

There is no general requirement for a family to be legally represented at a PIR. Many families attend without a Barrister or Solicitor, particularly where the circumstances are relatively straightforward and there are no substantial disputes.

Representation may be especially helpful where:

The death involved a public authority;
Article 2 may be engaged;
Several organisations are represented;
The evidence is extensive or technical;
Expert evidence is disputed;
There is disagreement about the scope or witnesses;
A jury may be required; or
The family is concerned that an important issue is not being investigated.

For further guidance, see Do I Need a Barrister for an Inquest?

Practical Takeaways

A Pre-Inquest Review is a case-management hearing, not the final inquest.
Not every case requires a PIR.
Important decisions may be made about scope, witnesses, disclosure, experts, Article 2 and a jury.
Families should read the available evidence and identify their principal concerns in advance.
Any missing documents or proposed witnesses should be raised clearly.
The family can ask questions and make representations in ordinary language.
The Coroner will usually issue directions explaining what must happen next.
Important disagreements should be raised as early as possible.

Final Thoughts

A Pre-Inquest Review can shape the investigation which follows. It may determine not only the practical arrangements for the final hearing, but also the evidence which will be gathered and the issues which will ultimately be examined.

Families do not need to master coronial law before attending. The most useful preparation is to identify their principal concerns, consider what evidence may address them and raise any important gaps in the material already obtained.

Further information about advice and representation is available on the Contact page.