A coroner's inquest is a public judicial inquiry designed to uncover the facts surrounding a death, which can be instrumental in helping to determine its causes. Here is what typically happens at a coroner’s inquest:

• Notification and initial investigation: when a death occurs in a hospital under unclear or troubling circumstances, it is reported to the coroner. The coroner initiates an investigation, which may include a preliminary review of medical records and a postmortem examination to establish the initial cause of death.
• Opening the inquest: the inquest is formally opened to officially record the identity of the deceased, and the time, place and cause of death. This initial hearing is usually brief and serves to set the parameters for the full inquest investigation.
• Gathering evidence: the coroner gathers all relevant evidence to understand the circumstances surrounding the death. This includes obtaining detailed medical records, post-mortem examination reports, and any previous treatments the deceased received. Witness statements from medical professionals, hospital staff and family members are also collected.
• Expert reports: during the inquest, the coroner may call upon medical experts to provide their professional opinions on the care and treatment the deceased received. These experts can offer insights into whether the standard of care met legal and professional requirements and if any failings may have contributed to the death.
• Inquest hearing: the core of the inquest is the public hearing, where all the gathered evidence is presented and examined. Witnesses, including doctors, nurses and other relevant parties, may be called to give evidence and answer questions. Interested persons, such as family members and their legal representatives, can also participate, asking questions and providing additional information.
• Legal representation: solicitors will advocate on behalf of the family, ensuring their concerns are addressed, asking pertinent questions, and challenging inconsistencies in the evidence. They help clarify complex medical terminology and procedures, making the process more understandable for the family.

After all the evidence has been presented and reviewed, the coroner decides on an inquest conclusion.  The coroner can choose a ‘short form’ conclusion as the cause of the death such as ‘natural causes’, ‘suicide’, ‘misadventure, ‘lawful/unlawful killing’. If none of these is appropriate then the coroner might choose a ‘narrative ‘conclusion’ that is tailored to this specific death but is still factual in content. 

The coroner can also choose to add to each conclusion that it was ‘contributed to by neglect’ if this is their finding.

Under the Coroners and Justice Act 2009, a coroner has a duty to issue a Regulation 28 Prevention of Future Deaths (PFD) Report to an individual or organisation in any cases where it is determined that action needs to be taken to prevent further deaths.

A Regulation 28 report outlines the specific concerns identified during the inquest. In a medical negligence case, this might include failings in medical care, gaps in communication between healthcare professionals, procedural errors, or deficiencies in hospital protocols. The report will detail the coroner’s findings and the rationale for believing that similar deaths could occur unless changes are made. It also includes recommendations for action, which may range from improving training and supervision of medical staff to revising clinical procedures and enhancing patient safety measures.

Once a Regulation 28 report is issued, it is sent to the relevant organisation or authority responsible for addressing the identified issues. These recipients are required to respond within 56 days, outlining the actions they have taken or plan to take in response to the report. This response is then reviewed by the coroner, and both the report and the response are made publicly available, ensuring transparency and accountability. If the coroner is not satisfied with the response, they may take further steps to ensure that the necessary changes are implemented.

The purpose of these reports is to prevent the occurrence or continuation of any circumstances that might increase the risk of other deaths occurring. They ensure that the lessons learned from each inquest lead to meaningful changes, safeguarding lives and improving the quality of care provided to patients.

A coroner may request an inquest when a death in a hospital setting requires further investigation to determine the cause and circumstances. Here are key reasons why a coroner might call for an inquest in such cases:

• Unexplained or sudden deaths: inquests are necessary if a person died unexpectedly or without an apparent cause to determine what happened.
• Suspicion of medical negligence: if medical negligence is suspected to have contributed to a patient’s death, an inquest examines the standard of care and identifies any errors.
• Multiple deaths: multiple patient deaths under similar circumstances in a short period can trigger an inquest to identify common factors or systemic issues.

Hospital inquests play a vital role in uncovering the truth, addressing potential medical failings, and improving healthcare standards. They provide answers to families and contribute to a safer healthcare environment by ensuring transparency and accountability.

You can request a coroner's inquest if you believe it is necessary to determine the cause of death, particularly in a hospital setting where medical negligence is suspected. If you have concerns about the circumstances surrounding a loved one’s death in a hospital, you can contact the coroner’s office and provide detailed information supporting your request. Presenting compelling evidence and clearly explaining why an inquest is warranted can influence the coroner’s decision to proceed with the inquiry. A medical negligence solicitor can help you with this if they believe there are grounds. 

The letter will outline why you are an interested person in the matter and what potential failings have occurred to mean that an inquest is necessary. In cases of suspected medical negligence, requesting an inquest might involve highlighting discrepancies in medical records, inconsistencies in the accounts of healthcare professionals, or providing expert medical opinions that question the standard of care provided. Families may also gather witness statements from other patients or staff members who can shed light on the care their loved one received. A thorough presentation of these concerns can help the coroner understand why an inquest is necessary to investigate potential failings and prevent similar incidents in the future.

When making a request, it is beneficial to work with experienced inquest solicitors who can guide you through the process and help compile a strong case. Legal representatives can assist in drafting the request, ensuring all relevant details are included, and liaising with the coroner’s office on your behalf. The specialist lawyers at JMW can assist with submitting a request for an inquest, providing assistance in drafting the request, ensuring all relevant details are included, and liaising with the coroner’s office on your behalf.

You have the right to full disclosure of all the relevant documents held by the coroner. There is also the right to request any evidence you feel is relevant to the inquest that hasn’t already been requested by the coroner. This can be requested from the coroner’s office. 

Prior to the inquest, you will be provided with the final inquest bundle. It is often worth reviewing this bundle to ensure that nothing is missing. Due to the sensitive information contained in the bundle, this can be a distressing process; as such, one of the team here at JMW can review this on your behalf. This can help ensure that the bundle contains all the necessary evidence, without requiring you to review all of the evidence yourself.

A witness statement is the means by which you will be able to set out your concerns about the circumstances of your loved one’s death. This allows you to specify the questions that you and your family may have - for example, concerns about the treatment your loved one received before they died. A statement can also set out information about your loved one, who they were and what they were like. Additionally, it is important that your witness statement works through the chronology of the events.

The team at JMW have significant experience in drafting witness statements for inquests. Get in touch with us, and we can help to lay out exactly what type of information should be included in the statement.

In a hospital setting, certain deaths must be reported to the coroner to ensure a thorough and independent investigation into the cause and circumstances of death. These situations often involve unexpected, unexplained or unnatural deaths, including:

• Unexpected or sudden death: when a patient dies unexpectedly or without a clear medical cause, hospital staff are required to report the death to the coroner. This is particularly important if the patient was not previously diagnosed with a condition that would explain the sudden death.
• Suspicion of medical negligence: deaths suspected to be linked to medical negligence must be reported to the coroner. This includes instances where there may have been errors in diagnosis, treatment, or care that could have led to the patient’s death.
• Violent or unnatural death: any death resulting from accidents, surgical complications, or other unnatural causes in a hospital setting must be reported. For example, if a patient dies due to an unexpected reaction to a medication, a surgical error, or an unforeseen complication during a medical procedure, these incidents will be subject to a coroner’s inquest.
• Deaths in state detention: deaths occurring in state detention, including psychiatric hospitals, are automatically referred to the coroner.

Reporting these deaths to the coroner allows for an independent review of the circumstances surrounding the death and helps to identify any areas where practice can be improved.

A pre-inquest review, also known as a pre-inquest review hearing, is an administrative hearing that will be held when an inquest is complex, or there are a number of interested persons involved. All of these indivudals and their representatives will usually be present.

The coroner will use these reviews to make decisions about the practical arrangements of the inquest. As with the inquest itself, you are able to attend these hearings. You can expect them to last around an hour or longer, depending on the complexity of the case.

The duration of inquests vary significantly, particularly in hospital-related cases where the circumstances surrounding the death may be complex. Hospital inquests often involve detailed examinations of medical records, witness testimonies from healthcare professionals, and expert medical opinions, all of which can extend the timeframe.

From 2013 onwards, most inquests should take place within six months of the date of the death, but this can take longer in parts in certain parts of the country with larger backlogs.

The coroner must give at least 14 days notice of the date that the inquest will take place. The following will be notified: 

• Family members of the deceased 
• Witnesses who are required to attend 
• Anyone else that the coroner believes should be notified of the inquest

The inquest hearing itself will be held over several days, or spread out over weeks if there are numerous witnesses to be heard and substantial evidence to be reviewed. For hospital inquests, it is not uncommon for the hearing to be adjourned to allow for further investigation or to obtain additional expert reports.

The length of the overall process will also need to take into account the availability of witnesses, the coroner's court schedule, the time taken to examine the evidence, and time for the coroner to deliberate and compile a comprehensive report. As such, the overall duration of a hospital inquest, from the initial report of the death to the final conclusion, can range from a few months to over a year, depending on the complexity and specifics of the case.

If the police charge someone with causing the death, the inquest will not be resumed, and the next of kin will be informed of the arrangements made to register the death. This is to avoid two different courts examining the same evidence.

Requesting an adjournment can be done for various reasons:

• The evidence that is going to be relied upon in the inquest is provided too late, meaning there is insufficient time to review the evidence ahead of the inquest.
• You haven’t had enough time to instruct a lawyer and seek legal advice.
• You haven’t had enough time to apply for Legal Aid funding.
• The coroner decides that they need to call certain witnesses or request an expert.
• The coroner decides that some further investigations or enquiries need to be carried out.
• You need to submit further written evidence and the coroner agrees it is necessary.
• You want to make submissions to the coroner on the scope of the inquest.

Speak to a solicitor to learn more about how this process works.