Practical Guidance

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…

Introduction Most inquests are heard by a Coroner sitting alone. Jury inquests are comparatively unusual now, although in medieval times, all inquests were held with jurors. Ministry of Justice statistics record that 527 inquests were held with juries in England and Wales during 2025, representing approximately 1% of all inquests. However, jury inquests are more…

Introduction An inquest and a civil claim may examine many of the same events, documents and witnesses. They do not, however, perform the same legal function. The purpose of an inquest is to determine who the deceased was and how, when and where they came by their death. Where the procedural obligation under Article 2…

Introduction One of the most common questions families ask at the beginning of the inquest process is whether they actually need legal representation. The answer depends entirely on the nature of the case. Some inquests are relatively straightforward and proceed without legal representation for any party. Others involve multiple public bodies, extensive disclosure, expert evidence…

Introduction At the conclusion of an inquest, the Coroner – or in some cases the jury – must reach a formal conclusion about the death. For many families, conclusions are one of the most significant stages of the entire inquest process. The conclusion records the Coroner’s (or jury’s) findings regarding how the deceased came by…

Introduction For many families, an inquest is something they encounter entirely unexpectedly and at one of the most difficult periods of their lives. The process can feel unfamiliar, formal and intimidating, particularly where there are numerous witnesses, legal representatives, medical records or complex procedural issues. An inquest is not a criminal trial and it is…

“Accident” and “Misadventure” are closely related short-form conclusions available to a Coroner or Jury. In simple terms: Both conclusions mean that the death was not intentional. For a general overview of the inquest process, see About Inquests. The Legal Meaning Although the terminology can sound archaic, the distinction is practical rather than technical. Historically, “misadventure”…

What Does a Suicide Conclusion Mean? A conclusion of suicide means that the Coroner or Jury is satisfied that: It is a serious and carefully scrutinised conclusion. Coroners are required to direct themselves or the Jury with particular care before it can be returned. Chapter 15 of the Chief Coroner’s Bench Book provides guidance to…

Introdcution – What is Interested Person Status? Interested Person (usually abbreviated to “IP”) status is a formal designation under section 47(2) of the Coroners and Justice Act 2009, giving individuals specific rights to participate in an inquest. The Chief Coroner’s Revised Guidance – Chapter 2 explains that an Interested Person is someone whom the Coroner…

Introduction Few aspects of an inquest attract as much attention, or perhaps as much misunderstanding, as a Prevention of Future Death report (often shortened to a “PFD Report”). The statutory foundation lies in Schedule 5 paragraph 7 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.…