What Can And Can’t I Expect At An Inquest?

What is an Inquest?

An Inquest is a public judicial inquiry into the death of an individual. It is ultimately a fact-finding process where a Coroner will answer four important questions:

1. Who the deceased was
2. When and where they died
3. The medical cause of their death
4. How they came by their death

In most cases, the first two questions are relatively straightforward. and they are arguably a hangover from the establishment of the Coroners’ Service in 1194.

Importantly, a Coroner cannot deal with issues of blame or responsibility for an individual’s death, these are matters which need to be addressed through either a civil claim or criminal liability.

Why has an Inquest been opened?

If an individual has died and there is reasonable cause to suspect that their death was not due to anything other than “natural causes”, then a Coroner is legally required to open an inquest into the death. Doctors and health professionals can make referrals to the Coroner if they consider that a death was “non-natural”. For example, if a medical procedure or treatment may have directly caused or contributed to that person’s death. A Coroner must also investigate the death of anyone who has died whilst under the care or custody of the State.

Why is the Coroner opening an investigation and not an inquest?

The Coroners’ Service has been (and arguably remains) under considerable pressure. Since 2013, steps have been taken to try and manage coronial resources and to minimise the stress and anxiety to family members. If a death is reported to the Coroner and it seems likely that the person died due to natural causes but the initial post mortem has not revealed a cause of death, the Coroner can open an investigation to try and obtain the additional information they need to answer the questions they need answering. Generally, an investigation should only be opened if the questions the Coroner needs to answer are relatively straightforward.

How can I raise my concerns?

You should be allocated a Coroner’s Officer who will act as a liaison between you and the Coroner. They will be responsible for collating all the evidence together which the Coroner will then review. The Coroner’s Officer will likely contact you to obtain a statement about your family member’s background and any relevant medical history. This is an opportunity for you to raise any concerns about the circumstances surrounding your loved one’s death. Alternatively, as these statements are often taken quite soon after a loved one has passed away, you can always write to the Coroner separately.

Does there need to be a Pre-Inquest Review Hearing?

Different Coroners have different approaches to the management of Inquests. In relatively straightforward cases it may not be necessary to have a Pre-Inquest Review Hearing; however, in complex cases, or if you as a family have concerns about the witnesses the Coroner proposes to call and the scope of their enquiries, it may be necessary to have (and you may want to ask for) a Pre-Inquest Review Hearing to decide on some of these issue.

Will I be provided with any documents before the Inquest?

All inquests should be open and transparent and once the Coroner has collated all of the evidence, be it an independent report from an expert and/or factual accounts from witnesses, this should be shared with you. Generally, Coroners prefer to wait until they have all the evidence before sending it out, so it is not disclosed in a piecemeal fashion. Quite often, but not always, the Coroner will have access to your family member’s medical records but if you have any concerns that they do not have certain pieces of information which you think are relevant, raise this with the Coroner’s Officer. You can also obtain copies of a deceased family member’s medical records by applying directly to the hospital Trust or GP practice.

Quite often documents will contain technical and detailed medical information and potentially upsetting descriptions. If you are worried that you may find the information distressing, you can always ask not to receive documents, or have them sent to another nominated contact on your behalf.

What happens at a Coroner’s Court?

A Coroner’s court is less formal than a civil or criminal trial. Coroners do not wear a wig and if you are legally represented your lawyer will not wear a gown. A court usher will be present and will let you know what to do when the Coroner arrives and leaves court, and if you are speaking to the Coroner they should be addressed as Sir or Ma’am.

When the inquest starts, the Coroner will usually first explain what an Inquest is and the issues they intend to cover. If witnesses are giving live evidence, they will be sworn in and then the Coroner will ask them questions. Once the Coroner has asked their questions, any other “interested parties” can ask questions. As a family member, you can ask questions of the witness. The Coroner may also admit certain documents or statements in to evidence, rather than asking the person who wrote them to attend Court. In this case, the Coroner will read out the statement or paraphrase it.

Once all of the evidence has been heard, the Coroner will give their conclusion and if there are legal representatives present, they will have the opportunity to address the Coroner before they reach their conclusion.

What can a Coroner conclude?

Importantly, an inquest is not a trial. The Coroner cannot make any decisions which relate to guilt, blame or compensation. It is purely a fact-finding inquiry and the Coroner cannot sentence individuals or penalise them.

What a Coroner can do is make findings of fact and answer the four questions set out above. When answering “how” a person came by their death, Coroners are often directed to give what is known as a “short form” conclusion. This is a very restricted list of conclusions which are often only a couple of words. If a short form conclusion is not appropriate, the Coroner can give a narrative conclusion, but again, these are still relatively short and may only be a few lines. Importantly, any narrative should be “brief, neutral and clear” and it must not appear to determine any question of criminal or civil liability.

What is the point if the Coroner won’t hold anyone accountable?

Quite often the inquest leaves families with more questions than answers. It can be a lengthy process and one which can ultimately leave families feeling a little deflated, as they may not understand what has happened, why it has happened, and whether their loved one’s death could have been prevented. The limitations placed on Coroners in law are such that they are actively prevented from holding anyone to account; however, by going through this process families can often obtain additional information which would not normally be disclosed until much later on in a civil or criminal case.

Do I need legal representation?

This is entirely a decision for you. When a loved one has died it is already a deeply distressing time, but in circumstances where there may be question marks over that individual’s death, it is even more uncertain. If an Inquest involves an institution, like a hospital, they will likely be legally represented. They will have access to specialists who understand the procedure and can speak to medically qualified individuals about what happened. For families who are trying to grieve for a loved one, it can be a bit of a lottery as to how much support they receive in navigating this, at times, lengthy, detailed and complex process.

The benefits of instructing a specialist in this area, is that they can lighten the load on the family. We can review the evidence that has already been obtained, make suggestions about what further evidence may be needed, ask questions of the witnesses, identify additional issues and make suggestions to the Coroner regarding the scope of the inquest, and also advise you on the possibility of a civil claim.