Human Rights
By Conal McGarrity
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Everything You Need To Know About A Coroner’s Inquest

In the UK, upon a person’s death, a medical practitioner will register that death. However, 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 result in the need for a coroner’s inquest. An inquest is usually held in a public court where the coroner will examine the circumstances of the person’s death and sometimes calls relevant witnesses to give evidence about how the deceased came to die. An inquest 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.

That being said, the evidence a coroner obtains as part of their investigation are frequently relevant to any civil proceedings that may arise from the circumstances of death.

When Will The Coroner Investigate a Death?

The circumstances that will require a coroner to investigate a death are when:

  • the deceased died a violent or unnatural death 

  • the cause of death is unknown

  • the 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.

What Questions Will The Coroner’s Investigation Look To Answer?

The main 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.

What Will The Outcome Of The Coroner’s 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.

Who Can Participate In A Coroner’s Investigation?

Those who the coroner considers ‘interested persons’ 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.

Will There Be A Jury Present?

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;

  • 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 in the wider public interest.

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.

However, 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.

How Can P.A.Duffy & Co Help You With An Inquest?

The death of a loved one is an extremely distressing time for anyone and a coroner’s inquest can be very intimidating, especially for families who have no experience of the legal system.

If you believe that a person’s death was someone’s fault (after an accident, or treatment which went wrong) then you should take specialist legal advice.

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