medical negligence

A Guide to a Coroner’s Inquest

coroners inquests, two people holding hands across a table, giving each other emotional support

If you or your family are facing an inquest you do not need to go through it alone. We recognise it is important for the family that there is a proper investigation into a person’s death and our specialist team dealing with coroners inquests are here to help. Tees have many years’ experience of guiding, advising and representing families through the inquest process. In some cases, medical practices have been changed as a consequence. In some personal injury, medical negligence or Human Rights Act claims for compensation have followed. Most importantly, in all cases the family have left the inquest with understanding of what went wrong and satisfied that the right questions were asked and answered. 

What are coroner's inquests? 

Coroner's inquests involve investigation into the death of the deceased person.

An inquest is only held in certain circumstances, for example;

  • If a person dies suddenly and the cause is unknown
  • They died in a violent or unnatural way or if the death occurred whilst detained under the mental health act
  • In a hospital or care setting or if they were in custody or state detention
  • Deaths can also be referred to the local coroner by a doctor if they are unable to ascertain the cause of death, if death occurred during an operation or if the cause was violent or unnatural
  • Deaths can also be referred to the coroner by the police, a registrar of deaths or members of the public 

If death occurs in one of these situations, then the local coroner may have a duty to investigate the deceased’s death. This investigation can include holding an inquest.  

Coroner's inquests are held in public. The inquest is a thorough investigation to establish the details of the death and should help family members understand what happened. It is an impartial, thorough and public fact-finding investigation, set up and conducted by a coroner.  An inquest is not designed to assign blame or responsibility for a death; it seeks to ascertain four questions: who died, how they died, and when and where the death occurred.   

Article 2 Inquests  

Article 2 inquests are enhanced inquests held in cases where the state or 'its agents' have 'failed to protect the deceased against a human threat or other risk' or where there has been a death in custody, this can be either where the deceased is detained in hospital or state detention. 

These types of inquest have an increased scope and will enable the coroner to consider additional details which may be relevant to the circumstances of how the deceased came about their death. 

Prevention of future death reports  

This is known as a 'report under regulation 28' or a prevention of future deaths report because the power comes from regulation 28 of the coroner's (inquests) regulations 2013. The regulation gives the coroner the power to send a report to the people or organisations who are in a position to take action to reduce the risk which has been established during the inquest. 

What is a coroner and what does a coroner do? 

A coroner is an independent judicial officer, who is appointed and paid by a local authority. Coroners must either be a qualified barrister, solicitor or a chartered legal executive with 5 years’ experience. They investigate unexplained sudden deaths; violent or unnatural deaths and, deaths for which a doctor is unable to issue a medical certificate of the cause of death. The coroner is required to investigate the cause of death, which can include launching an inquest. 

Will there be a post-mortem? 

A post-mortem (also called an autopsy) is an examination of the body after death by a qualified pathologist to assist in determining the cause of death. The coroner has complete discretion about whether a post-mortem should be performed. You cannot object to a coroner’s post-mortem - although the decision should be made with sensitivity and should consider as far as possible the relatives’ views and any religious and cultural sensitivity. The coroner must give notice of the date, time and place of the post-mortem to the next of kin, personal representative and any other interested person who has notified the coroner in advance of their desire to be represented at the post-mortem. 

Some post-mortems can be done non-invasively, such as by MRI scanning, but this is still very rare. You can instruct a medical practitioner to attend to represent you at the post-mortem – but this is also quite rare, and fees will be charged. 

What happens at the post-mortem? 

The coroner will appoint a pathologist to conduct a post-mortem. The pathologist should be independent where a death has occurred in hospital and where there are concerns about the contribution of treatment to the death, the pathologist should be from another hospital or area. 

The coroner has authority to remove from the body and preserve material that has a bearing upon the cause of death. This could include organs or tissue. The coroner cannot retain these after the inquest has concluded without the consent of the relatives. 

What happens after the post-mortem? 

After the pathologist has finished, the coroner will usually authorise the release of the body and then funeral arrangements can be made. The pathologist will then provide a post-mortem report to the coroner. It will usually be possible to apply for a copy although sometimes the coroner will not release this until the inquest itself. The report should contain a detailed analysis of the deceased’s body and then provide conclusions about the cause of death. The post-mortem can include other medical factors which contributed to the person’s death.  

If you would like legal support during this difficult time, talk to us today.

When will the inquest take place? 

Usually, an inquest opens soon after a death has occurred. Most coroners aim to complete inquests within 6-9 months of the initial report of the death. In the meantime:  

  • The coroner can issue a certificate of the fact of death which can be used to notify asset holders – this is often referred to as the interim death certificate.  
  • The coroner will gather relevant information such as medical records and witness statements. 
  • The coroner will usually contact the family to explain that an inquest is to be held.  
  • The coroner may decide to hold a pre-inquest review in some cases which aims to ensure all relevant documentation is obtained and all expert evidence required is obtained in readiness for the inquest itself. 
  • The coroner may decide to instruct independent experts to prepare reports into the circumstances of the death. 
  • Usually, relevant documentation will be shared with the family ahead of the inquest to allow them the chance to review and consider any questions they wish to raise. These questions can be directed to the coroner to ask at the inquest. 
  • The funeral can be arranged as soon as the coroner confirms the post-mortem is complete. 
  • A grant of probate can be obtained by the personal representative of the deceased. 
  • The death cannot be finally registered until after the inquest has been completed.   

What happens at the inquest? 

At the inquest, the coroner’s job is to establish the facts about the death. During an inquest, the coroner may: 

  • Call individual witnesses to give evidence (for example, police officers, doctors or nurses) 
  • Ask the family to talk about the deceased (for example, their family life and work) 
  • Call specialist witnesses to give evidence (such as medical experts). 
  • The Coroner will ask witnesses and experts further questions in order to establish a full picture of what happened. 
  • Interested persons will then have an opportunity to ask questions of the witnesses as well.  
  • In certain circumstances, a jury may be present. 

Typically, the pathologist will give evidence first. It is usual for Coroners to ask relatives whether they wish to leave the room whilst the post-mortem is read out. The witnesses are invited to present their evidence: this may be by reading a prepared statement or by answering questions.  

“The conclusion”: What will happen at the end of the inquest? 

At the end of an inquest, the coroner or jury will deliver a conclusion as to the death of the deceased and the category of death. The conclusion will explain the details of the death. The conclusion will decide from several categories of death the law recognises: - 

  • Natural causes 
  • Open verdict
  • Suicide 
  • Accident/misadventure 
  • A disaster which has been the subject of a public inquiry 
  • Lawful killing 
  • Unlawful 
  • Industrial disease 
  • Stillbirth 

Whilst the purpose of the inquest is not to apportion blame, where mistakes have been made, it is part of the purpose of the inquest to identify those mistakes. In appropriate cases, the coroner will make recommendations to ensure that those mistakes are not repeated.   

The coroner and the jury, where applicable, can give longer narrative conclusions which can provide more detail in instances where medical mistakes for example have contributed to the death. 

After an inquest, the coroner will send the necessary details of the death to the registry of births and deaths. 

Inquests are recorded and interested parties are able to request a copy of the recording.  

Should I have legal representation for the inquest? 

Many families find it enormously helpful to have legal representation, to guide and support them through an “alien” process at what is already a difficult and emotional time in their lives. This is particularly so where they are concerned, for example, about the care that the deceased received and whether this caused or contributed to their death. 

Although most coroners will do what they can to assist the person’s family, it can be very difficult for families to ensure an effective investigation into the deceased’s death and participate effectively in an inquest without proper representation.  

State bodies including health Trusts will usually be represented by barristers who will ask witnesses questions on their client’s behalf, it can therefore be extremely helpful for families to be represented themselves in circumstances where complex healthcare issues are to be discussed during the inquest. 

If you are considering and wish to explore the possibility of obtaining legal representation at an inquest, please do contact us and we would be happy to discuss this further with you, at no cost. 

Call our specialist solicitors on 0808 231 1320

Tees are here to help

We have many specialist lawyers who are based in:

EssexBrentwoodChelmsford, and Saffron Walden
HertfordshireBishop's Stortford and Royston

But we can help you wherever you are in England and Wales.

Chat to the Author, Craig Knightley

Associate, Medical Negligence, Chelmsford office

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