Losing a loved one in sudden or unexpected circumstances is one of the most painful experiences anyone can face. When the circumstances of the death are unclear, or if questions remain about how and why the deceased person died, the inquest process provides an opportunity to gather information and seek answers. For family members, it can bring clarity but also feel like a daunting journey through unfamiliar legal territory.

A coroner’s inquest can be an emotional and complex experience. The inquest hearing may involve reviewing all the evidence, listening to witness statements, and reliving traumatic events. However, it plays a vital role in establishing the medical cause of death, highlighting failings, and identifying any reasonable causes for concern that could help prevent future harm.

At JMW, we understand how overwhelming the inquest process can feel. That’s why we have created this guide to explain what happens when a coroner decides an inquest is necessary, covering both the legal and emotional realities of involvement. If you need guidance at any stage - whether preparing for the final hearing or understanding how the inquest process interacts with criminal or civil liability - our experienced inquest solicitors are here to help.

Why Might You Need to Be Involved in an Inquest?

A coroner’s inquest is a fact-finding inquiry into the circumstances of a person’s death. If you have lost a loved one under unexpected, unexplained or potentially avoidable circumstances, you may find yourself involved in this legal investigation. While the inquest process does not seek to apportion blame or determine criminal or civil liability, it aims to establish the cause of death and examine whether any failings contributed to it.

A coroner will decide to hold an inquest when there is reasonable cause to suspect that a person died in circumstances requiring further investigation. These situations often include:

• Unexpected or unexplained deaths: If the medical cause of death is unclear following a post-mortem examination, the coroner’s court may need to gather more evidence.
• Deaths following medical treatment: When concerns are raised about possible medical negligence or failings in care, the inquest process may investigate whether lapses in standards contributed to the death.
• Deaths in state custody: If a person dies in prison, police custody, or under the care of mental health services, an inquest hearing is required by law.
• Workplace accidents or other incidents: Fatalities caused by accidents, industrial disease or dangerous conditions at work may trigger an inquest to examine potential health and safety breaches.

For family members, attending an inquest can be distressing. In addition to mourning a relative’s death, you may need to review all the evidence, hear witnesses give evidence, and relive painful details about how the death occurred. However, understanding the purpose of the inquest process can help you see it as an important step in understanding why your loved one died and potentially preventing similar incidents in the future.

At its core, an inquest hearing seeks to answer four key questions:

1. Who the deceased person was.
2. When they died.
3. Where they died.
4. How and in what circumstances the death occurred.

While the process can be daunting, it provides an opportunity for families to gain answers, clarity, and hopefully a sense that justice has been served. Inquests also play a critical role in improving safety standards and preventing future tragedies.

What Are the Steps of the Inquest Process?

While every inquest is different, there are several key stages that most inquests follow. Understanding these steps can help you prepare for what lies ahead and feel more in control during a difficult time.

1. The coroner's investigation

After a death is reported, the coroner will decide whether an inquest is necessary. This usually happens when:

• The cause of death is unknown.
• There are concerns about how the deceased person died, such as possible medical negligence or failings in care.
• The death occurred in suspicious circumstances or in state custody.

At this stage, the coroner may order a post-mortem examination to help establish the medical cause of death. If the results provide a clear explanation, an inquest may not be needed. However, if further investigation is required, the inquest process will move forward.

2. Opening the inquest and gathering evidence

Once the coroner confirms that an inquest is necessary, they will officially open the case. This usually involves a brief public hearing where the coroner's officer provides basic details about the deceased person, and the coroner sets a date for the final hearing.

From this point, the coroner begins gathering all the evidence needed to determine how the death occurred. In hospital inquest cases, this may involve reviewing medical records and post-mortem reports, or taking witness statements from doctors, nurses and other medical staff.

As a family member, you may be asked to provide a statement or attend the hearing as a properly interested person (PIP). This means you have the right to see evidence, ask questions, and be legally represented if needed.

3. The inquest hearing

When the inquest reaches the final hearing, you may need to attend coroner’s court. This can be an emotional experience, as you will hear detailed evidence about your loved one’s final moments. Witnesses, including medical professionals or other relevant parties, will give evidence, and you may have the opportunity to ask questions through your legal representatives.

Depending on the complexity of the case, the hearing may last anywhere from a few hours to several days. Some inquests involve a jury, but in most inquests, the coroner alone will decide the outcome.

4. The conclusion

At the end of the inquest, the coroner will issue their conclusion based on the evidence presented. This is their official finding about how the death occurred. Once the inquest is complete, the coroner will issue the final death certificate, allowing you to register the death officially. However, this is not always the end of the process.

Many families are left with further questions, particularly if the inquest highlights serious failings in care. If the coroner or jury finds that a person’s death was caused or contributed to by medical errors, this could suggest that the care provided was substandard. In these cases, you may be able to pursue a medical negligence claim.

How Do Inquests Help to Prevent Future Harm from Occurring?

While the primary aim of an inquest hearing is to uncover the circumstances of the death, its impact often goes beyond providing answers. For family members coping with the aftermath of medical negligence or a hospital-related death, a key concern is ensuring that similar mistakes do not happen again. Knowing that the inquest process can lead to improved standards of care may offer some people comfort during an otherwise distressing time.

A coroner’s inquest can highlight critical issues in hospital care that may have contributed to how a deceased person died. Some of the most common concerns include:

• Delays in diagnosis or treatment: Was a medical cause of death preventable if the person had received earlier intervention?
• Inadequate monitoring of patients: Were warning signs of deterioration ignored or missed?
• Breakdowns in communication: Were crucial post-mortem examinations, test results, or patient needs miscommunicated?
• Staffing and resource challenges: Did a lack of trained staff or essential equipment affect the quality of care?

By gathering all the evidence and scrutinising hospital processes, an inquest hearing not only provides clarity for grieving families but can also expose failures that need to be addressed.

If an inquest identifies failings that pose a risk to future patients, the coroner will decide whether to issue a report to Prevent Future Deaths (PFD). This report is sent to the NHS trust or relevant healthcare provider, who must respond by outlining the steps they will take to prevent similar fatalities.

For example, a PFD report might recommend:

• Strengthening safety protocols for detecting sepsis or responding to medical emergencies.
• Improving hospital policies on patient monitoring and escalation procedures.
• Increasing staff training on recognising and addressing high-risk situations.
• Investing in staffing levels or medical equipment to improve patient care.

For many families, taking part in the coroner’s court proceedings is about more than finding out how their relative’s death occurred - it is about pushing for accountability and preventing others from suffering in the same way. By sharing their experiences and engaging with the process, families can drive meaningful change in hospital care and patient safety.

What Are the Challenges of the Inquest Process?

The inquest process is designed to uncover the facts surrounding a deceased person’s death, but for many families, it can also be a challenging experience. Our clients have often expressed difficulties with the following aspects of the process in particular:

Handling the complex process

One of the biggest challenges families face during the inquest process is ensuring they have the right support to navigate what can be a complex and emotionally demanding experience. Coroner’s court procedures can be difficult to follow, and families may be required to listen to evidence from the medical professionals who were involved in their loved one’s care. Having expert legal representatives by your side can make a significant difference, ensuring you feel supported and able to engage fully in the process.

Specialist medical negligence or inquest solicitors can manage the whole process for families, from providing essential information to the coroner, to instructing leading barristers to question those responsible for the healthcare organisation. 

In many cases, NHS trusts and other public bodies have experienced legal teams representing their interests. Without legal representation of their own, families may struggle to:

• Understand the legal process and their rights as properly interested persons
• Question witnesses effectively and ensure key concerns are addressed
• Identify and challenge inconsistencies in the evidence presented

This is why it is so important to seek expert legal advice, so families can ensure they have a strong voice throughout the inquest. Legal representation not only helps in gathering information and making legal submissions where necessary, but also ensures that the inquest is as thorough and fair as possible. With the right support, families can focus on finding answers and ensuring lessons are learned to prevent future deaths.

Limitations of the inquest process

While an inquest hearing plays an important role in uncovering facts, it has significant legal limitations that can be frustrating for families seeking accountability:

• No apportioning of blame: The coroner’s inquest is a fact-finding inquiry, not a trial. This means the coroner will decide the cause of death but cannot make findings of criminal or civil liability or state that a particular individual or organisation was at fault.
• Limited scope: The inquest process focuses on answering only questions relating to the individual person's death. It may not examine systemic failings in detail or consider wider issues that contributed to the death.

Limitations of Prevention of Future Deaths orders

Prevention of Future Deaths (PFD) orders are among the most significant tools available to coroners when they identify risks that could lead to further fatalities. However, while PFD orders can be useful in highlighting health and safety concerns or deficiencies in hospital policies, they have several limitations:

• Focus on individual trusts: PFD orders are often sent to a single NHS trust, rather than addressing problems across the wider healthcare system. This means broader issues may go unaddressed.
• Delays or lack of response: Some trusts take months to respond to PFD orders, while others fail to act on them at all.
• No follow-up monitoring: Once a trust issues a response, there is little oversight to ensure that real changes are made. This can leave families feeling frustrated, knowing that the same mistakes could happen again.

Given these challenges, attending an inquest can be tough, but having expert legal representatives to support you with your inquest can make a significant difference.

What Is Article 2, and How Does it Relate to Inquests?

Article 2 of the European Convention on Human Rights protects the right to life and places a duty on the state to safeguard individuals. In the context of inquests, Article 2 may be engaged when there is reason to believe that the state - or those acting on its behalf - failed in their duty to protect a person's life.

When Article 2 applies, it triggers an enhanced inquest, meaning the coroner’s inquest must go beyond simply determining how the death occurred and examine whether the state failed in its duty to protect the deceased person.

Although medical negligence cases often involve concerns about failings in care, the threshold for engaging Article 2 in a hospital inquest is very high. Generally, an enhanced inquest will only be launched if there is evidence of:

• Systemic failings within an NHS trust that go beyond individual errors.
• Gross negligence or a complete failure to provide medical care to a patient who was entirely dependent on the state.

Most hospital inquests proceed as standard inquests, rather than enhanced Article 2 inquiries. However, where there are concerns about systemic issues or a wider risk to public safety, legal representatives can argue for Article 2 to be engaged.

How We Can Support You at Inquest

The inquest process can be overwhelming for families, especially when facing public bodies with extensive legal representation. At JMW, we step in to bridge the gap and give you full support throughout the process. Our team provides expert legal representation, guiding you through every stage, reviewing evidence, and challenging any inconsistencies or gaps in the information presented.

Providing a level playing field against large legal teams

Many families find themselves at a disadvantage during an inquest hearing, particularly when NHS trusts and other organisations have access to public funds to instruct large legal teams. We ensure you are not left to navigate the legal process alone. Our solicitors:

• Provide clear guidance on your rights and the coroner’s inquest process.
• Help you prepare for the hearing and ensure your voice is heard.
• Analyse and challenge evidence, including medical records, witness statements, and post-mortem reports.
• Make legal submissions on issues such as PFDs.

We are able to provide representation that is of an equal standard to the legal teams you will be facing, making sure that your interests are represented robustly.

Proven expertise in inquests and medical negligence

JMW’s expertise in both inquests and medical negligence claims allows us to take a comprehensive approach to your case. While the coroner’s court does not assign civil liability, we keep a close eye on potential clinical negligence issues throughout the fact-finding inquiry.

If the coroner or jury finds that a person’s death was caused or contributed to by neglect of healthcare workers, this could indicate that the care provided was substandard. We can advise you on whether there are grounds to pursue a claim for compensation and help you take the next steps towards securing justice.

Funding your legal representation

We recognise that accessing legal representation can be challenging for families. At JMW, we offer representation where there is a clinical negligence element to the case, and private representation at inquest. If there is evidence that mistakes have been made this, this can be covered through a no win, no fee agreement, meaning you will not need to pay anything out of pocket for your legal representation. We can also advise on legal expenses insurance, which in some cases may cover your inquest representation if linked to a medical negligence claim.