When the cause of a person’s death is unknown, was violent or unnatural, or occurred in custody or state detention, including under the Mental Health Act, an inquest is required. 

An inquest is a formal legal investigation carried out by a coroner to determine the circumstances of a person’s death. The coroner does not make any decisions regarding criminal or civil liability, or seek to assign blame - an inquest is a fact-finding process to clarify the circumstances of the death and ensures that deaths, particularly those that are sudden, unexplained or suspicious, are thoroughly examined.

Families are considered “interested persons” in the inquest process, which in turn grants them the right to participate in the proceedings and access relevant documentation. It can also offer an opportunity to ask questions and find out more about what happened to a loved one. 

While legal representation at an inquest is not a mandatory part of the process, legal representation from an experienced clinical negligence solicitor should be sought if it is believed that medical failures played a role in a loved one’s death and an inquest is to be held. The experienced team at JMW can guide you through the inquest process, from gathering and analysing evidence, to representing your interests during the inquest hearing and helping you to understand your options following the inquest conclusion. 

Here, we explain how the inquest process works, when inquests are required, and the legal action that can be taken following an inquest conclusion.

When Will an Inquest Take Place?

An inquest is required if:

• The death was unexpected or unexplained
• The person suffered a violent or unnatural death
• The death occurred while the person was in state detention or care, including under the Mental Health Act

A death is usually reported to the coroner if there are, for example, concerns that medical treatment or a failure to act by hospital doctors may have contributed to a person's death. If the cause of death is unclear, an interim death certificate will be issued, which confirms the identity of the deceased and the fact of death but does not provide further details such as the cause of death. Following the inquest conclusion, a final death certificate will be issued.

In some cases, if the death happened in state custody or under the Mental Health Act, an enhanced inquest, known as an Article 2 inquest, may be held. This means that the coroner will look more closely at whether the state (which includes hospitals) failed in its duty to protect life. These inquests are broader and involve procedural and policy issues, depending on what the coroner decides.

Alongside determining the circumstances of a person’s death, a coroner also has a duty to prevent future deaths by addressing systemic failings. If the coroner decides that there is a risk that other deaths could occur in the future if action is not taken, they will usually issue a Prevention of Future Deaths Report. This is sent to the relevant organisation - for example, a hospital trust or authority - to highlight areas of concern and to request that changes be made. Interested persons will usually receive a copy of the report if one is issued. Organisations receiving such a report must respond to the coroner within 56 days, outlining their actions to address the issues identified during the inquest. 

Can I Attend the Inquest?

Interested persons are invited to attend inquest proceedings at the coroner's court and offer evidence of their own. Organisations are often legally represented and in circumstances where the death of a loved one may have been due to medical errors, it is beneficial for families to instruct a solicitor specialising in medical negligence to represent their interests at the inquest.

JMW's medical negligence team can guide families through the inquest process, from gathering and analysing evidence to representing their interests at the hearing. They can also instruct a barrister to question witnesses, ensuring a thorough and impartial investigation.

Family members may be given the opportunity to ask relevant questions - either directly or through their legal representative. The coroner’s job is to make the process as open and fair as possible, whilst also ensuring that only the relevant issues are explored. 

What Does an Inquest Involve?

An inquest seeks to determine the circumstances of a person’s death. The coroner’s role is to answer four main questions:

1. Who the deceased was
2. When they died
3. Where they died
4. How they died, including the cause of death and the circumstances surrounding the death

The last question can require a more in-depth investigation, involving a review of medical records and witness statements from healthcare professionals and the deceased’s family, particularly when clinical decisions or the treatment provided are in question. 

Prior to the inquest process, the coroner may request a post-mortem examination, although this is not necessary in every case. They may also obtain copy medical records and witness statements from doctors, nurses, and other staff involved in the care. An inquest is a public hearing and can last from a few hours to several days or longer, depending on the complexity of the case. 

During the hearing, witnesses can be asked to give oral evidence, medical professionals may be asked to explain their decisions and experts might be instructed by the coroner to offer independent views to assist them with their investigation. As part of their inquiry, the coroner can consider issues including the treatment provided and whether this was appropriate, whether there were any omissions in the treatment provided and whether medical staff followed the correct procedures.

What Are the Potential Outcomes of an Inquest?

After reviewing the evidence, the coroner will conclude how the person died. Conclusions can be short-form, such as “natural causes”, "accidental death" or “unlawful killing”. Coroners can also reach a narrative conclusion, which is more detailed and specific to the case. In Article 2 inquests, the conclusion may include terms like “missed opportunities” or “inadequate failures.” If neglect contributed to the death, this may also be included in the conclusion.

As mentioned, the coroner does not apportion blame. However, if a coroner concludes that a loved one’s death was contributed to by medical failures, there may be grounds to bring a claim for medical negligence.

To bring a successful compensation claim for medical negligence, it must be proven that:

• A duty of care existed between the medical professional/hospital trust and the deceased
• There was a breach of this duty of care - for example, this could be a delay in treatment, misdiagnosis or a failure to act
• The breach of duty caused or materially contributed to the death

The solicitor will gather the relevant evidence, including obtaining expert evidence on the standard of care provided and whether any failures caused the death. Thereafter, allegations can be sent to the NHS trust, GP or other primary care provider responsible for the treatment provided. This can also include private healthcare providers.

Compensation following a death due to medical negligence can include:

• An award for the injury and the pain suffered as a result
• Bereavement damages- a lump sum award if a loved one has passed away due to negligence
• Funeral expenses
• Loss of financial support (if a loved one contributed to household income)
• Loss of services (if a loved one carried out tasks such as childcare and household tasks)

It is important to work with an experienced medical negligence solicitor to build the strongest possible case. JMW’s medical negligence team has a wealth of experience in claims and can support you throughout the inquest process, all the way through to a successful claim for compensation.

In many cases, we offer a no win, no fee arrangement (also known as a Conditional Fee Agreement) for medical negligence claims. While no amount of money will compensate for the loss of a loved one, it can help to cover the costs incurred and provide access to the necessary support. It can also help to make sure similar incidents are prevented in the future, and hold to account the people responsible for a loved one's death.

Talk to Us

Many families choose to speak to a medical negligence solicitor on being notified by the coroner's office that the death of their loved one is to be investigated. A solicitor can help you understand your rights, represent your interests at the hearing, and advise you on whether you may have a claim for compensation. The medical negligence team at JMW has represented many people in situations like yours, from the initial information-gathering through to any follow-up legal action that is available.

Contact us to learn more about how we can help. Call JMW on 0345 872 6666 or use our online enquiry form to request a call back.