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What is a Coroner's Inquest?

Medical practitioners register most deaths in the UK. In certain situations, a coroner may investigate the death and conclude as to how the person died, before registering the death.  
This investigation can sometimes include a coroner’s inquest. This inquest - held in a public court except in exceptional circumstances – sees the coroner examine the circumstances of death and sometimes calls relevant witnesses to give evidence about how the deceased died.
It is entirely separate from any civil or criminal proceedings that may arise out of a death. A coroner is also prohibited from making findings determining questions of civil or criminal liability. 
However, the evidence a coroner obtains as part of their investigation, and the conclusions reached about the death, are frequently relevant to any civil proceedings that may arise from the circumstances of death. 
If you have lost relatives and are involved in coroner’s inquest proceedings, at Leigh Day, we can help. 
Ready to talk? Get in touch with Suzanne White, a member of the INQUEST Lawyers Group, to discuss your coroner’s inquest case. Call 020 7650 1200 or 

When will the coroner investigate the circumstances of a death?

The Coroners and Justice Act 2009 lists the circumstances requiring a coroner to investigate a death. 
These are when the:
  • Deceased died a violent or unnatural death 
  • Cause of death is unknown 
  • Deceased died while in custody or state detention

The coroner has a broad range of discretion in deciding what constitutes a violent or unnatural death. 
In circumstances where a person has died of a natural cause a coroner may find the death to be unnatural if there’s reason to suspect the condition was triggered or accelerated by inappropriate treatment or exposure to dangerous materials, such as asbestos. This will then require a coroner’s investigation.
The Coroners and Justice Act also requires a coroner to investigate all deaths that occur in state detention. This includes all deaths in prison and the deaths of patients detained under the Mental Health Act

What questions will the investigation look to answer?

The purpose of a coroner’s investigation is to answer the following key questions:
  • Who was the deceased?
  • When did the deceased die?
  • Where did the deceased die?
  • How did the deceased die? 

A coroner usually has wide-ranging discretion determining how someone died. However, in certain circumstances, Article 2 of the European Convention of Human Rights (ECHR) requires a coroner to undertake an enhanced investigation to examine the ‘broad circumstances’ of how a person arrived at their death. 
Very simply, such an investigation is required if a person has died in state detention and in circumstances where the state is, arguably, implicated. This could be when a state body failed to provide adequate systems to prevent the death occurring and/or if a state body has been grossly negligent (to the extent it could be considered criminal). 
In such investigations, coroners must ensure the person’s next of kin are fully involved, and the investigation is effective and independent.

Will a jury be called to an inquest?

Only a coroner can decide to empanel a jury. The circumstances requiring the gathering of a jury include when the:
  • Deceased died in custody and a coroner has reason to suspect the death was a violent or unnatural one, or the cause of the death is unknown. 
  • Death resulted from a “notifiable accident, poisoning or disease” and needs reporting to the Health and Safety Executive. These include deaths caused by an accident in the workplace. They also cover deaths in healthcare settings following the suicide of a patient or their murder by another patient. 
  • Death occurred in circumstances that the continuance of which are prejudicial to the health and safety of the public. 

The views of the deceased's family should always be considered by a coroner as well when deciding whether to call a jury. 
A coroner also has a right to summon a jury simply if they feel there’s sufficient reason for doing so. This can be if there is evidence of some fault or omission on behalf of a state agent, or there’s a particular need for increased public scrutiny.

What will the outcome of the investigation be?

At the end of the investigation, the coroner will complete a Record of Inquest. This document includes:
  • Determinations relating to who the deceased was, where, when and how they died.
  • Conclusion as to the death – the verdict in either short form (e.g.: ‘natural causes’) or a longer narrative. 

The conclusion must not be framed in a way that might determine any question of civil or criminal liability on the part of a named person. 
However, if a coroner feels the investigation shows existing circumstances pose a risk of further deaths and that actions should be taken, the coroner is under a duty to make a report. This can be very important for families seeking to ensure steps are taken so the circumstances leading to the death of a loved one are no longer allowed to exist.

How can Leigh Day help you with an inquest?

We can help you during the inquest process in many ways: 
  • Obtaining  the deceased person's medical and other records – Making formal requests for records to a GP, hospital, care home, prison or private company and liaising with the coroner’s office for disclosure of records. 
  • Obtaining independent expert evidence – Using expert reports from medical professionals, such as pathologists, and asking the coroner to hear such evidence. 
  • Making legal submissions to the coroner – Submissions to the coroner’s courts regarding a more thorough investigation, whether to summon a jury or call witnesses and more. 
  • Instructing a barrister to represent the family at court hearings – Arranging representation for family members for inquest hearings that last days, weeks or longer.
  • Liaising with the press and preparing press releases – Our specialist media relations team assist families in managing press interest sensitively and appropriately.  
Contact our expert solicitors about your inquest case by:

Coroner’s Inquest: FAQs

Who can participate in a coroner’s investigation?

Those who the coroner considers interested persons, as defined in the Coroners and Justice Act, are entitled to participate. They could include:
  • Spouse, civil partner or partner
  • Parent, grandparent, stepfather or stepmother 
  • Child, grandchild, niece or nephew
  • Brother, sister, half-brother or half-sister
  • Personal representative of the deceased
  • Person who may by any act or omission have caused or contributed to the death of the deceased, or whose employee or agent may have done so
The rights of an interested person to participate in an inquest include the right to:
  • Be notified of an inquest date within one week of the date being set. 
  • Be provided with any document held by the coroner that is requested (unless the coroner considers such a request unreasonable or there is another lawful reason not to disclose).
  • Ask questions of any witness giving evidence at the inquest.

What funding is available for representation at an inquest?

In extremely limited circumstances, Legal Aid is available for the provision of legal advice and representation at an inquest. We can negotiate flexible fixed fee arrangements, which you can pay for in instalments for work associated with preparation for an inquest. We arrange such agreements on a case-by-case basis.
If a death was caused or contributed to by negligence or a violation of the deceased’s human rights, and a successful civil claim arises from the death, reasonable legal costs associated with preparation for and representation at an inquest should be recoverable from the defendant to such a claim. 
There is a range of funding options available for investigations into civil claims at Leigh Day. These include a Conditional Fee Agreement (“No win no fee”) or funding through Legal Expense Insurance.

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