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 not intended to determine liability – either criminal or civil. Instead, the purpose of the inquest is to investigate Who the deceased was, and When, Where and How they came by their death. Together, these are often referred to as the “4 Statutory Questions”.
In some cases, particularly where the state may have played a role in the death, the scope of the investigation can be significantly wider. This wider scope is called an Article 2 Inquest and you can read more about it here. There’s also a guide for families about Article 2 Inquests
This article explains the inquest process step-by-step and outlines what families can generally expect from beginning to end.
What Is an Inquest?
An inquest is a public investigation conducted and overseen by a Coroner.
Coroners are independent judicial office holders responsible for investigating certain deaths. Not every death leads to an inquest. The Coroner will usually become involved where the death was sudden, unexplained, violent, unnatural, occurred in custody or may have resulted from state involvement.
The legal framework is principally governed by the Coroners and Justice Act 2009 and, less so, the Coroners (Inquests) Rules 2013.
The purpose of the inquest is usually limited to determining:
- Who the deceased was;
- When they died;
- Where they died; and
- How they came by their death.
The final question – how the deceased came by their death – is often the most significant and, in some cases, the most legally complex. Importantly, “How” someone came by their death is different to “Why” someone died.
Stage One – The Death Is Reported to the Coroner
The process generally begins when a death is reported to the Coroner by a doctor, hospital, police force, prison, care provider or another public authority.
The Coroner will initially decide whether:
- No further action is required;
- Further enquiries are required; or
- A formal investigation and inquest should be opened.
At this stage, the Coroner may obtain preliminary statements, medical records or information from relevant agencies.
Stage Two – Opening the Investigation
If the Coroner decides that a formal investigation is necessary, the inquest will usually be formally opened. Opening an inquest happens in public, but is usually just a formality.
This hearing is often brief and administrative in nature. The Coroner may confirm:
- The identity of the deceased;
- The provisional medical cause of death;
- Whether a post-mortem examination has taken place; and
- Whether further hearings will be required.
In some cases, the Coroner will also identify individuals or organisations who are likely to become Interested Persons.
Stage Three – Disclosure of Evidence
Once the investigation is underway, the Coroner will gather evidence relevant to the death. This can include:
- Medical records;
- Witness statements;
- CCTV footage;
- Prison or custody records;
- Ambulance records;
- Internal investigations;
- Expert evidence; and
- Photographs, body-worn video or scene evidence.
Interested Persons are usually entitled to disclosure of the relevant material that other organisations provide.
In more complex inquests, disclosure can become extensive and disputes sometimes arise regarding relevance, redactions or sensitive material.
Stage Four – Pre-Inquest Review Hearings
In more straightforward cases, the matter may proceed directly to a final hearing.
However, many inquests involve one or more pre-inquest review hearings, often referred to as PIR hearings.
These hearings are used to manage the case and determine issues such as:
- The scope of the investigation;
- Disclosure disputes;
- Witness evidence;
- Expert evidence;
- Whether Article 2 is engaged;
- Whether a jury is required; and
- The likely length of the final hearing and practicalities about its location and so on.
PIR hearings can be particularly important in cases involving hospitals, prisons, mental health detention, police contact or alleged systemic failings.
Stage Five – The Final Inquest Hearing
The final hearing is the stage most families associate with the inquest process.
The hearing itself varies significantly depending on complexity. Some inquests conclude within an hour. Others may last several weeks.
The Coroner will usually hear oral evidence from witnesses and may also consider documentary evidence.
Interested Persons, and their legal representatives, may ask questions of witnesses. The purpose of questioning is not to establish blame but to assist the Coroner in investigating the circumstances of the death. Witnesses who give evidence are not cross-examined and people asking questions of witnesses must not be aggressive.
Families are often understandably anxious about attending court. However, Coroners are generally conscious of the sensitive nature of proceedings and many courts make practical arrangements to assist families wherever possible.
Stage Six – Conclusions
At the end of the evidence, the Coroner – or in ceratin cases the jury – will reach a conclusion.
This may take the form of:
- A short-form conclusion, such as accident, suicide or natural causes; or
- A narrative conclusion setting out factual findings in greater detail.
The conclusion must not determine, or appear to determine, criminal guilt or civil liability.
However, factual findings made during an inquest can still have very significant consequences and may later be relevant in related proceedings.
Stage Seven – Prevention of Future Deaths Reports
In some cases, the Coroner may conclude that there is a risk of future deaths occurring unless action is taken.
Where that threshold is met, the Coroner must issue a Prevention of Future Deaths Report, often referred to as a PFD report.
These reports can be directed to hospitals, public authorities, government departments, companies or other organisations. The recipient is then required to respond formally.
Do Families Need Legal Representation?
Not every inquest requires legal representation.
However, representation can be particularly valuable where:
- The death occurred in custody or detention;
- There are allegations of failings in medical treatment;
- Multiple public bodies are legally represented;
- The case involves Article 2 issues;
- There are large volumes of disclosure; or
- The family wishes to challenge the scope of the investigation.
A Barrister can assist with preparation, legal submissions, witness questioning and ensuring that the family’s concerns are properly advanced.
Practical Takeaways
- An inquest is an investigation, not a criminal trial.
- The process usually involves disclosure, witness evidence and legal argument.
- Many cases involve preliminary hearings before the final inquest.
- Families can participate in the process and may ask questions through legal representatives.
- Complex cases involving hospitals, prisons, police or mental health detention frequently benefit from specialist legal advice.
Final Thoughts
The inquest process can feel overwhelming, particularly for families already dealing with grief and uncertainty.
Understanding the structure of the process is often the first step towards making it feel more manageable.
Every case is different. Some inquests are relatively straightforward, while others involve extensive investigations into the actions of public bodies or healthcare providers.
Early legal advice can often assist families in understanding the scope of the investigation, the issues likely to arise and the practical steps available to them throughout the process.