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A Guide To Coroners Inquests

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An inquest is a legal procedure presided over by a coroner. It takes the form of a fact-finding investigation with the purpose of determining the circumstances in which someone has come to their death. Inquests are not the appropriate forum for apportioning blame – indeed they are expressly prohibited from doing so. They usually have the relatively narrow aim of establishing answers to the following four questions:

  1. Who was the deceased?
  2. When did they die?
  3. Where did they die?
  4. How did they die? (In terms of the medical cause of death)

When is an inquest held?

An inquest does not have to be held for every death. There are certain circumstances when a coroner will usually hold an inquest (this is not an exhaustive list):

  1. There is reasonable cause to suspect that the death was unnatural, violent or suspicious
  2. The cause of death is unknown
  3. Death occurred whilst the deceased was in contact with an arm of the state, such as in prison, hospital or police custody

Is there a jury?

Inquests are not usually heard in front of a jury; however there are cases in which it is mandatory. It was formerly the case that whenever a death occurred in state custody, an inquest automatically had to be held before a jury; however, this is no longer the case. Jury inquests are now no longer mandatory, unless the death occurred in the custody of the state andone of the following also applies:

  1. the death was violent or unnatural, or of unknown cause
  2. the death resulted from an act or omission of a police officer or member of a service police force in the purported execution of their duties
  3. the death was caused by an accident, poisoning or disease which must be reported to a government department or inspector

Article 2 inquests

Article 2 of the European Convention on Human Rights (ECHR) – the “right to life” – creates an obligation on the state to properly investigate losses of life in their jurisdiction. Through previously decided case law, there is now an obligation on the coroner in cases where Article 2 is engaged to hold a wider investigation into the circumstances in which the deceased came by their death. This allows the coroner to investigate earlier failings in the prison or healthcare system which may have more than minimally caused or contributed to the  death.

Who is represented at an inquest?

The represented parties at an inquest are known as properly interested persons (PIP’s), and they can essentially be anyone whom the coroner believes is entitled to ask questions of the witnesses. With a death in custody, the usual PIP’s are the family of the deceased; the establishment where the death occurred; any institution who was directly involved in the care of the deceased; and occasionally the Ministry of Justice. Each of the PIP’s usually has legal representation, and they are all able in turn to ask questions of the witnesses called by the coroner, and make submissions to him/her in relation to any questions of law that might arise.

What happens at an inquest?

The inquest itself looks on the face of it like any other court hearing, in that there is a judge (the coroner), lawyers, witnesses and (sometimes) a jury. However, there are some key differences that set inquests apart from criminal and civil hearings. The key feature is that the proceedings are “inquisitorial” as opposed to “adversarial” – the inquest is simply tasked with investigating the circumstances of the death, as opposed to there being a case contested by two sides. Each witness is first questioned by the coroner in order to obtain the relevant evidence. The advocates representing the PIP’s are then permitted to ask relevant questions to assist the Coroner’s enquiry. An unusual feature of inquests is that the jury (if there is one) can also ask questions of the witnesses.

Once the court has heard from all of the witnesses in relation to the circumstances of the death, the coroner is then able to call witnesses from the PIP’s to address any concerns that have arisen that might give him/her cause for concern that there is a risk of further deaths occurring in the same establishment. This is often referred to as Regulation 28 evidence, as it relates to the coroner’s power under Regulation 28 of The Coroners (Investigations) Regulations 2013, which allows him/her to publish a report on any such issues that have arisen. Indeed, the coroner is duty-bound  under the Coroners and Justice Act 2009 to make such a report, if he/she believes that action is required to reduce or prevent the risk of further deaths that has been identified. If there is a jury, then the coroner will hear this evidence in their absence, as the jury are only concerned with determining the factual circumstances of the death – the prevention of future deaths is a matter for the coroner alone.


At the end of an inquest, the coroner (or jury, if there is one) retires to consider the evidence heard during the inquest. They then return with what are now known as their conclusions as to the cause of death. Prior to the coroner/jury retiring to consider their conclusions, there is the opportunity for the PIP’s to address the coroner on which of the available conclusions and issues are “safe” to be left for the jury to consider, that is to say those which could be supported by the evidence that has been heard. Again, these legal arguments are heard in the absence of the jury. The conclusions available to the coroner/jury are as follows:

  • accident or misadventure (the unintended consequence of an intentional act)
  • alcohol/drug related
  • industrial disease
  • lawful killing
  • unlawful killing
  • natural causes
  • open conclusion
  • road traffic collision
  • stillbirth
  • suicide

The coroner/jury may also choose to return a narrative conclusion. This means that they produce a paragraph which factually describes the circumstances of the death. Narratives are not permitted to name any individual, and they cannot use words or phrases which look to administer civil or criminal liability. They do, however, allow the coroner/jury to make wider comments on any failings or issues with the care received by the deceased, or any failures to foresee risks that they feel caused or contributed to the death. This is particularly relevant in Article 2 inquests, where the legal scope for what can be said to have caused or contributed to the death is much wider.

The inquest ends with the coroner/jury completing a Record of Inquest and reading out their conclusions, followed by the coroner giving his/her determination as to whether there will be a Report to Prevent Future Deaths. All of these reports are published on the Chief Coroner’s website and form the basis of the Chief Coroner’s Annual Report to the Lord Chancellor.

What happens next?

What follows on from the inquest usually depends on the evidence that has come out during the hearing.

  1. If the coroner has chosen to produce a Report to Prevent Future Deaths then the parties to whom it is addressed must provide a proper response within 56 days of the date on which the report is sent. The response must set out any action or proposals that the institution has implemented in order to address the concern raised by the coroner.
  2. If there are failings on the part of the institution where the deceased was being held or treated, which have caused or contributed to the death, then there may be a possibility of a civil claim for damages against the offending institution.

How can we help?

At Minton Morrill, we specialise in inquest law and have established a national reputation in the area, having acted in some of the most high-profile inquests in the country in recent years – most notably the inquest into the deaths of Christi and Bobby Shepherd (the Corfu case involving Thomas Cook).

We are not interested in the deceased’s background – our aim is to ensure that the Deceased and the bereaved family’s voice is heard throughout the inquest process and that the family are able to obtain the answers they need in relation to their loved one’s death.

During the process, we work closely with a number of organisations, including the Prison and Probation Ombudsman Service, the Independent Police Complaints Commission and NHS trusts. We also have close links with INQUEST, a leading UK charity supporting bereaved families at inquests. Legal Aid may also be available in exceptional circumstances, which we can help you apply for, should you be eligible.

We also have a nationally-renowned civil litigation department, and can therefore take the case on to a civil claim for damages, if appropriate. In addition, our private client department can assist with any issues in relation to probate or letters of administration, so we are able to offer a full service to families, with expertise in all of the relevant areas of law.

To find out how our specialist inquest solicitors in Leeds, Yorkshire and the North of England can help you, please contact us on 0113 245 8549 or email