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It is extremely difficult for anyone dealing with the death of a loved one. In most cases when someone dies their death can be signed off by a doctor. However, in certain circumstances the death might have to be reported to a Coroner and an Inquest is opened. If you have lost a loved one as a result of suspected poor medical treatment and have been told that an Inquest has been opened into their death, we can help you by advising and guiding you through the inquest process.
How we can help you?
Our solicitors can help you with Inquests stemming from sub-standard medical treatment. Click here for more information about medical negligence Inquests.
What is a coroner’s inquest?
In certain situations when someone dies, their death must be reported to the Coroner. The Coroner is the person who investigates deaths in England and Wales. A death would be reported if:
- the cause of death is unknown;
- the death was violent or unnatural;
- the death was sudden and unexplained;
- the person who died was not visited by a medical practitioner during their final illness;
- a medical certificate is not available;
- the person who died was not seen by the doctor who signed the medical certificate within 14 days before death or after they died;
- the death occurred during an operation or before the person came out of anaesthetic; or
- the medical certificate suggests the death may have been caused by an industrial disease or industrial poisoning
The Coroner may decide that the cause of death is clear and therefore they would direct the doctor to sign the death certificate. However, in some cases if the cause of death is unclear the Coroner may request that a post-mortem is carried out.
An inquest is an investigation which is opened by the Coroner if after the above steps have been taken the cause of death is still unknown, or if the person:
- possibly died a violent or unnatural death
- died in state custody or detention
If you have been told by the coroner’s office that an inquest investigation is being opened into your loved ones death, please get in touch with our solicitors and we will be happy to discuss the specifics of your case.
What is the purpose of an inquest?
The purpose of the Inquest is to establish the answers to the following 4 questions;
- Who the Deceased was,
- Where the Deceased died,
- When the Deceased died, and
- How the Deceased died.
Following the conclusion of the Inquest the Coroner can then direct the registrar to register the death.
What will happen during an inquest investigation?
When a coroner opens the inquest he/she will direct for a number of enquiries to be carried out. This could include;
- Obtaining medical records;
- Taking witness statements;
- Obtaining expert reports;
- Obtaining prison records/police records/other relevant records
- Obtaining CCTV or other recordings of relevant evidence
In addition to the coroner’s own investigation there may also be other investigations being carried out alongside but independently of the coroner’s office. This may include;
- NHS Trust internal investigation;
- Care Quality Commission investigation; or
- Health and Safety Executive investigation
Often these investigations will result in a final report, which will then be disclosed as party of the coroner’s own investigation.
This process can inevitably take a considerable amount of time.
How long should the inquest process take?
The law states that an inquest should be dealt with as soon as possible but within 6 months from the date of death. However, it is accepted by the Chief Coroner (whom coroner’s have to report to) that more complicated deaths, in particular those involving the State, will take significantly longer.
Who might be involved in an inquest?
At an inquest there are parties called ‘Properly Interested Persons’ (PIPs) who take an active role in the process- they often include family members of the deceased, representatives of the establishment where the death occurred (if in custody at the time of death) and those who were directly involved in the care of the deceased. If a person is a PIP for the purposes of the Inquest then they are allowed to be legally represented. Each PIP is entitled to ask questions of any witnesses at an Inquest hearing and will receive any relevant documentation.
The parties who participate in an inquest are known as ‘Properly Interested Persons’ (PIP’s). This will often include family members of the deceased, the organisation(s) responsible for the establishment in which the death occurred, and any other individual or organisation involved in the care of the deceased, or whose conduct has been called into question in relation to the death. If the Coroner grants an organisation or individual PIP status, they are entitled to be legally represented at the inquest, ask questions of witnesses and receive copies of any relevant documentation.
What is a Pre Inquest Review Hearing?
Once the initial investigations have concluded and the PIP’s involved have received the relevant documents the Coroner may list a hearing known as a Pre-Inquest Review. This is a preliminary hearing where all PIP’s can be legally represented and they can make representations to the coroner on the need for any further witnesses, further disclosure, need for expert evidence, the scope of the inquest (the issues that will be considered), whether there should be a jury and, crucially, whether Article 2 European Convention on Human Rights is engaged. The coroner may also put a timetable in place to ensure that all further enquiries are carried out before the final Inquest is listed.
If you have been told that there will be a Pre Inquest Review Hearing into your family member’s death please contact a member of the team to discuss how we can help.
What happens at the end of an Inquest investigation?
At the end of the investigations the coroner will hold an Inquest Hearing. This is a formal fact-finding hearing where the court will explore the circumstances of the death. In some circumstances the hearing will be heard with a Jury and in others by a Coroner sitting alone.
In some situations if the circumstances leading to a death are straightforward the Coroner may hear the case himself without anyone present bar members of the Deceased’s family. However, in other cases where the death is more complex there will normally be a number of parties present who are likely to be legally represented.
At the Inquest the Coroner/jury will hear evidence that will assist them in answering the four important questions to establish who died, where they died, when they died and how they died. At the end of the evidence the Coroner/jury will deliver a conclusion based on all of the evidence heard. This conclusion will form the content of the death certificate.
Coroners also have an additional duty at the conclusion of an Inquest, which requires them to publish a report on any issues that have arisen during the course of the investigation which lead them to suspect that if action is not taken there is a risk that further deaths may occur.
If we think that there is a likely medical negligence claim stemming from a loved one’s death we may be able to offer you a No Win No Fee Agreement to pay for your legal representation at the Inquest and for a medical negligence investigation. Contact us to discuss Inquest funding options.
Frequently Asked Questions about inquests
Are inquest results made public?
The public can attend an Inquest and therefore the media may attend and report on the evidence heard at an Inquest and the conclusion. The Coroner will at the end of the Inquest answer the four questions as mentioned about in order to complete the death certificate. The death certificate is a matter of public record.
If the Coroner decides to prepare a report in line with Regulation 28 of the Coroner and Justice Act (as referred to above) then this report is also a matter of public record and so is the response by the public body the report is directed to.
What does “narrative Conclusion” mean?
At the end of an inquest a conclusion must be reached in relation to the death. These used to be called an “Inquest Verdict” but since the changes in the Law in 2013 they are now referred to as a “conclusion”.
Possible conclusions include:
- 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
The Coroner may also be in a position to return a narrative conclusion. This means that they produce a paragraph which factually describes the circumstances of the death. Narratives cannot name any individuals or use words or phrases which apportion civil or criminal liability but they can be used to make wider comments on any failings or issues which have been raised during the Inquest.
Will there be a jury?
Inquests are not usually heard in front of a jury; however there are cases in which it is mandatory. This is the case if the death occurred in the custody of the state and one of the following also applies:
- The death was violent or unnatural, or of unknown cause;
- 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; or
- The death was caused by an accident, poisoning or disease which must be reported to a government department or inspector
The Coroner does have discretion to call a jury where he/she feels that it is necessary or appropriate in the circumstances.
The role of the jury in an inquest is to listen to the factual evidence during the hearing and then follow the directions of the Coroner in completing the ‘Record of Inquest’, which will include their answers to the four key questions. The jury’s conclusion as to the “how” question will usually include one of the prescribed ‘short-form’ conclusions set out above.
What is an Article 2 Inquest?
Some families will hear the phrase “Article 2 inquest” during the course of an inquest investigation. This term refers to Article 2 of the European Convention on Human Rights, which is the right to life. Article 2 imposes a duty upon all State bodies, where there is a real and immediate risk to life of which they are (or ought to be) aware, to take all reasonable steps to mitigate that risk. It also imposes a separate duty on the State to carry out an effective investigation into any death that has occurred in circumstances where it appears this duty has been breached.
When Article 2 is engaged then the law requires a more comprehensive investigation into the circumstances of a death. Although the medical cause of death will ultimately be important for any conclusion, a thorough investigation will also be required into the wider circumstances leading up to the death. This is because quite often when the death has occurred whilst in the detention of the state, the death has occurred “behind closed doors”.
Article 2 can be engaged in a variety of different cases, but is regularly engaged in the following situations;
- Self inflicted death in prison
- Self inflicted death in police custody;
- Self inflicted death following police contact;
- Self inflicted death of a detainee in an immigration detention centre;
- Self inflicted death of a patient who is detained under a section of the Mental Health Act
- Self inflicted death of a voluntary patient on a psychiatric ward ;
- Police shooting;
- Some “natural causes” deaths in prisons (when the person had dies from a medical related illness but there are criticisms of the care received which likely caused or contributed to the death) and;
- Some “natural causes” deaths in police custody (when the person has died from a medical related illness but there are criticisms of the care received which likely caused or contributed to the death)
However, this is a complicated area of law which requires advice from one of our team as to whether Article 2 is engaged. Even if there is no current ruling that Article 2 is engaged we can draft legal submissions on your behalf when we believe the case does arguably engage Article 2. If you would like to speak to a member of our team please click here.
Can you get compensation following the inquest?
You cannot get compensation as part of the inquest process, however it may be that during the course of the investigations evidence is obtained to show that there may be grounds to bring a claim against individuals or organisations involved for causing the death.
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