Coroner’s court proceedings are opened after someone dies to find out more information about the death. This is called an inquest, and while they are not always necessary, an inquest may be launched if there are questions about a specific person’s death, including who they are, when, where and how they died. A coroner - an independent official who examines all of the deaths reported to them in a local jurisdiction - will decide whether an inquest is needed and, if so, will take charge of the proceedings.
Here, the expert coroner’s court solicitors at JMW explain how an inquest unfolds and the role a lawyer plays on behalf of interested persons or witnesses. By learning more about the parameters of a coroner’s investigation, you can understand the possible outcomes and determine whether you need legal representation.

What is an inquest?

The aim of a coroner’s court investigation is to establish the facts about someone’s death. It does not set out to apportion blame or responsibility for the death, but only to confirm the identity of the deceased, as well as where, when and how they died. Some inquests will examine the wider circumstances in which the death occurred.

An inquest may be opened if any of the following apply to a person’s death:

• It was unexpected or sudden.
• The cause was unknown after a post-mortem examination.
• It was violent or unnatural, including deaths by accident, suicide, or homicide.
• It happened in custody or another form of detention, which covers deaths in prison, police custody, psychiatric units, or immigration detention centres.
• Further investigation is needed to clarify the cause and manner of death.

These are all circumstances in which more information may be needed, and the coroner will try to answer all of the pertinent questions as a matter of public interest. If there is sufficient evidence of foul play, it may warrant further investigation by the police.

Often, when someone dies under unexpected or unexplained circumstances, it can be more difficult to grieve and come to terms with the situation. A solicitor can represent families to ensure that all of the important questions receive satisfactory answers. The questions also help authorities paint a full picture of the circumstances of your loved one’s death. Resolving any lingering doubts or concerns can help you to begin the healing process in earnest and bring peace of mind. In a different context, solicitors can represent care homes, local authorities, hospital trusts or regulated professionals at inquests. They will help with the disclosure process and manage the tasks the coroner wants those parties to undertake in compiling evidence for the inquest.

The inquest process

The process begins when the coroner formally opens the inquest. This typically involves a brief hearing to confirm the identity of the deceased and the fact of death. The deceased person must be positively identified, and this is usually done by a family member, friend, or someone else who knew the person in their life.

The inquest is then adjourned, so that an investigation can take place. The coroner will collect evidence, such as witness statements, medical records, reports from the police, and other relevant documents, to find information about the circumstances of the death. A post-mortem examination may be ordered if the medical cause of death is not clear.

Once the investigation is complete, the coroner holds a full inquest hearing, which is usually open to the public. The coroner will examine the evidence to determine the facts surrounding the death. This may include reading documents aloud, displaying evidence, and calling witnesses to testify, such as medical experts, family members, and anyone else who might have relevant information. Lawyers play a part in gathering the evidence and may suggest lines of enquiry to the coroner during the investigation. They help prepare witness statements or submissions on points of law. They attend pre-inquest review hearings to deal with issues raised by the coroner in preparation for the final hearing. During the final hearing, they may ask questions of witnesses under oath to uncover more information about the death. Especially in complex investigations, lawyers help the coroner in the gathering and rational presentation of evidence.

If you represent a business or organisation and have been asked to provide a statement or give testimony related to someone’s death, working with a solicitor can make a real difference. Even though an inquest does not aim to apportion blame, solicitors will advise on whether disclosure of particular evidence to an inquest is justified and if so, how it should be done to avoid other problems. The team at JMW can advise you on your legal obligation to answer specific questions and help you to mount a defence if you expect that further civil or criminal investigations might ensue.

The length and complexity of a final inquest hearing can vary significantly depending on the nature of the death, but will result in the coroner reaching a determination. If the inquest involves a jury, they will reach verdicts on the questions set by the coroner. The conclusion aims to answer four main questions, as we have described above: who the deceased was, and where, when, and how they died. The coroner's conclusion might include terms like "accidental death," "suicide," "unlawful killing," or "natural causes," among others. In some cases, a narrative conclusion is provided that summarises the circumstances of the death. If a jury is involved (usually referred to as an Article 2 inquest), the coroner may set a series of questions for the jury to answer upon considering the evidence on those issues.

If the inquest reveals systemic issues or risks to public health or safety, the coroner may make recommendations designed to prevent similar deaths in the future, and issue these in a report. In order to produce the report, the coroner may direct one of the interested persons, such as a hospital trust or the police to report upon how they plan to address matters of concern raised during the inquest.
Once the determination and any recommendations have been made, the coroner will formally close the proceedings. This means that after the formal conclusion has been rendered, there is very little scope for more evidence or questions. Interested persons must therefore work with a solicitor to make sure that disclosure is obtained and questions are asked to ensure a fair outcome before the inquest closes. Challenging a coroner’s determination can be complex and very expensive, assuming there are grounds to do so, but an experienced solicitor can support you.