An Inquest is a public hearing, looking into the facts that the Coroner has to establish: who has died, when, where, and how. If there is any doubt about any of these things - or if it appears that the circumstances of death are in any way suspicious - the Coroner must hold an Inquest. Of deaths that are reported to the Coroner, only about 1/8 lead to an Inquest. This means that, on average, a little less than 1 in every 20 deaths is investigated at an Inquest.
Inquests are usually a two-stage process. The Coroner should "open" the Inquest as soon as possible but, in the majority of cases, proceedings are immediately "adjourned". This means that the full hearing is postponed until a later date. The initial hearing is sometimes known as a "preliminary Inquest".
In preparation for the full Inquest, the Coroner will conduct detailed enquiries into the circumstances of the death, and will put together a list of evidence to be considered and witnesses to be heard from. Statements will be taken from anyone who has relevant information to give.
If the death in question is the subject of criminal proceedings, and/or the events surrounding the death are to be investigated in a Public Inquiry, the Inquest will remain adjourned until those investigations have been completed. It is then up to the Coroner whether the Inquest proceedings should be re-opened. If he or she believes that all the necessary questions have been answered by the criminal proceedings / Public Inquiry, then the Coroner can have the death registered on the basis of those findings, and formally close the Inquest. If, on the other hand, there are good reasons for continuing with the Inquest (for example, when a criminal investigation has been unsuccessful), the Coroner may choose to re-open the Inquest. Under these circumstances, the full hearing will go ahead as normal (even though it may, by this time, be some time after the actual death).
Once all the necessary investigations have taken place, the Coroner will set a date for the full Inquest.
There are no rules governing the way in which an Inquest should be prepared for, and different Coroners have different ideas about their duties. This is especially true when it comes to the issue of how much information should be shared with interested parties. Some Coroners will provide a list of the witnesses who are to be called and/or the documentary evidence which is to be considered. Some will disclose copies of that documentation, including witness statements, to relatives of the deceased and other interested parties. Other Coroners refuse to share any such information.
Among the more helpful Coroners, it is becoming common to hold "pre-Inquest hearings". These are meetings at which the Coroner will set out the scope of the Inquest and the procedures that will be adopted. Interested parties, including the deceased's relatives, have a chance to raise queries about these matters with the Coroner. The Coroner, in turn, is able to find out how close an interest in proceedings the various parties are going to take (for example: Are they attending with legal representatives? Will they want to ask questions of the witnesses?) A recent governmental review has expressed approval of pre-Inquest hearings because, when they are used, "surprises are avoided and the participants can have their perspectives on key handling issues considered." However, they remain a matter for the Coroner's discretion, and there is nothing in the law to say they have to take place.
All Inquests take place in public, so anyone can follow proceedings. Members of the press often attend.
Proceedings are conducted by the Coroner, and the only other people who are allowed to participate are "properly interested parties". The definition of a properly interested party is set out in the law. Certain people will always qualify: the most important examples are close relatives of the deceased (their parent, child, or spouse), and any person who is implicated in the death. People who do not fall into these categories can ask the Coroner for the right to be seen as a properly interested party, but they will not necessarily be allowed to do so.
The evidence that is to be considered by an Inquest is selected by the Coroner. The Coroner must, at the beginning of the Inquest, list any documents that are to be considered as evidence. Properly interested parties are entitled to copies of these documents at this stage, if they have not already received them. Any properly interested party can object to the use of any document, if they believe that its contents are open to dispute. In effect, this means that the person who created the document will have to give oral testimony, so that his or her version of events can be challenged. If the document was created by a person who is now dead or unable to give oral testimony, the Coroner can admit it as evidence, whether or not anyone disputes its contents.
All witnesses begin by answering questions from the Coroner. When the Coroner has completed questioning, other properly interested parties have the right to "examine" (i.e. ask questions of) the witness. They can either do so themselves, or via a qualified legal representative. If the witness has a legal representative, he or she is allowed to ask the last questions the witness will face.
It is an important part of the law concerning Inquests that "No witness... shall be obliged to answer any question tending to incriminate himself." This means that any witness can refuse to answer a question when the information that would be disclosed by doing so might lead to his or her prosecution. The Coroner will know of this law, and should not ask a question that would put the witness in that position. If another party asks such a question, the Coroner is obliged to inform the witness that he or she may refuse to answer it. The witness is allowed to answer the question, if he or she wants to (this is known as "waiver of privilege"), but cannot be compelled to do so.
In a small number of Inquests (only about 1 in 30), the Coroner summons a jury to decide on the case. Some categories of case must always be heard in front of juries: deaths in prison and deaths that appear to have been caused by a police officer are important examples. The Coroner also has a wider discretion to summon a jury whenever he or she believes that the death in question occurred in circumstances that are of major public interest. When a jury is summoned, it takes on the Coroner's responsibility of delivering a verdict as to the circumstances of the death. However, they are not, under current law, allowed to participate in proceedings (e.g., by asking questions). The Coroner remains in control of the hearings, and will direct the jury before they retire to consider their findings. He or she may only allow the jury to consider a limited range of verdicts.
Media reports of Inquests often concentrate on what they call "the verdict". Strictly speaking, an Inquest's verdict is the full finding regarding the circumstances of death but, nowadays, the term is taken to refer to the "short-form" summary of the category of death into which the deceased's case is found to fit. The available verdicts are a matter of convention, rather than law; there is nothing to stop a Coroner or jury coming up with his or her own way or describing the death, but one or other of the recommended verdicts is invariably adopted. The currently recommended choices are:
These suggested verdicts appear on the form that the Coroner/jury has to fill out at the conclusion of the Inquest. They were originally designed to allow statistical analysis of the kind of findings Inquests reach, but they have become the standard way to summarise an Inquest's conclusions.
It is very important to understand that the findings of an Inquest are supposed to be purely factual: it should answer questions as to who died, where, when, and how, but it does not ask why. Not only is an Inquest an inappropriate forum for attributing blame, it is explicitly forbidden from doing so: the law states that "No verdict shall be framed in such a way as to appear to determine any question of criminal..., or civil liability." An Inquest into a murder can conclude that the deceased was the victim of an "unlawful killing" but, no matter how obvious the facts, it is not permitted to name the murderer, a responsibility that is reserved for the criminal courts.
However, the Coroner/jury is encouraged to add a "rider" to its verdict, if it concludes that the death in question was "aggravated by lack of care".
This is commonly known as a verdict of "neglect". Again, any form of wording that the Coroner/jury considers appropriate is permissible (so long as it does not break the rule about attributing blame). However, it is recommended that a finding of neglect is only suitable if the Coroner/jury adopts one of four specified verdicts: natural causes, industrial disease, dependence on drugs/non-dependent abuse of drugs, or want of attention at birth.
The circumstances under which a neglect verdict can be given are extremely serious (and extremely rare). The Courts - having reviewed various Coroners' Inquests - have emphasised that neglect is a very different thing from the kind of negligence that has to be proved in civil courts, stating that "Carelessness is insufficient to justify a verdict of neglect" and "Only a gross failure to provide adequate care will suffice." The Courts have also upheld the principle that, in very unusual cases, "neglect" can even be a verdict in its own right. A neglect verdict will be particularly appropriate in cases where the deceased is a victim of a failure of an agency of the State (e.g., the prison service, the police, or the NHS): where death has occurred due to defects in the system, rather than through an individual's negligence.
Once a verdict has been reached by the Coroner/jury, the Coroner should submit a death certificate to the Registrar of Births and Deaths, detailing the time, place, and findings of the Inquest.
One last duty of the Coroner is to make recommendations to any person or authority that, in his or her view, could take action to prevent similar deaths in future. These recommendations can be very simple (for example, after the Coroner has investigated a road accident, he or she may propose that better signposts are erected in the area where the accident took place), but they could also be more wide-ranging. Sadly, the evidence suggests that Coroners rarely take advantage of this opportunity (the proportion of Inquests after which such recommendations are made is less than 2%).
From the above, you will have noted that if you are a close relative of the deceased, you have certain rights with regard to Coroners' investigations and Inquests. The most significant entitlements are as follows:
If you are involved in an Inquest, and the Coroner who is handling your case is not following these regulations, please feel free to contact us to discuss how your rights can be enforced.