Guide To An Inquest

In certain situations when someone dies the death will be reported to a Coroner. A Coroner is the person who is appointed to investigate certain deaths in England and Wales. The most common reasons why a death may be reported are if your loved one died either a violent or unnatural death, if the cause of death is unknown or if they died whilst in custody or otherwise in state detention.

The Coroner may decide that an Inquest is therefore required in order to answer four questions.

1) Who the deceased was
2) Where they came by their death
3) When they came by their death

And most importantly for the family

4) How they came by their death

The following document provides you with a guide to an inquest. It will take you through the key stages and will provide you with some useful information about Inquests.

Engaging an Inquest solicitor can feel daunting but they will help guide you through the process step by step. Book an initial consultation as soon as possible.

An Inquest lawyer at this appointment will

• Discuss funding options – if legal help (a type of legal aid) is available the application process will be explained and relevant forms completed and funding application will be made
• Establish the circumstances leading up to your loved ones death and the concerns that you have arising out of it
• Establish who the Coroner is, who may be involved (NHS Trust, Mental Health Trusts, Police, Prison, Local Authority) (these are called Interested Persons)

The next step is for the solicitor to contact the relevant Coroner’s Court and inform them of our instruction. We will also ask to see copies of the relevant documents and witness statements gathered through their own investigation and will ask to be informed of any relevant dates of future hearings.

We will also contact the other Interested Persons so they are also aware of our involvement.

Inquest Fact

The Coroner can grant Interested Person status to a number of different people at an inquest these can include:

• a spouse, civil partner, partner, parent, child, brother, sister, grandparent, grandchild, child of a brother or sister, stepfather, stepmother, half-brother or half-sister;
• a personal representative of the deceased;
• a medical examiner exercising functions in relation to the death of the deceased;
• a beneficiary under a policy of insurance issued on the life of the deceased;
• the insurer who issued such a policy of insurance;
• a 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;
• in a case where the death may have been caused by an injury received in the course of an employment, or a disease prescribed under section 108 of the Social Security Contributions and Benefits Act 1992 (c. 4) (benefit in respect of prescribed industrial diseases, etc), a representative of a trade union of which the deceased was a member at the time of death;
• a person appointed by, or representative of, an enforcing authority;
• a person appointed by a Government department to attend an inquest into the death or to assist in, or provide evidence for the purposes of, an investigation into the death under this Part;
• any other person who the senior coroner thinks has a sufficient interest.

The next step will be to help you prepare a witness statement to be used at the Inquest. The statement will deal with

1) The background of the deceased
2) What you know about the circumstances leading up to the death
3) Will attach any documents in your possession that are relevant to the death (this may be letters/notes/emails)

We will also draft a Pen Portrait. A Pen Portrait is a 1-2 page document where you have the opportunity to tell the Court about who the deceased was, your happy memories, their personality and what they meant to you.

Once all the disclosure of documents and statements have been provided the Coroner may list what is called a Pre Inquest Review Hearing. This is a hearing to look at a number of matters including, scope and type of the inquest (what the inquest will look at), which witnesses will need to give evidence, what further documents we might need, whether an expert might be required, whether a jury is required and when the inquest might be listed.

At this stage we may also advise you that we need to apply for Exceptional Case Funding to cover your representation at the Inquest by one of our Solicitors or a specialist Barrister. An application for ECF funding for the inquest hearing is not means tested but will only be granted in certain circumstances.

Inquest Fact

Did you know….?

In certain circumstances the Coroner must sit with a Jury at the final inquest and the Jury will be required to listen to the evidence and make a determination on the facts at the end of the evidence.

A jury is mandated when the death occurred in state detention and either the death was violent, unnatural or unknown, or that it resulted from an act or omission from a police officer or a member of a service police force in the purported execution of their duty, or that it was caused by a notifiable accident, poisoning or disease.

The coroner also has a discretion to sit with a jury if they feel that there is sufficient reason to do so.

The Pre Inquest Review Hearing will take place in a Coroner’s Court. If there are other Interested Persons involved they will also attend with their lawyers. This hearing is essentially a case management hearing to make sure the investigation is ready for the final inquest.

At this hearing there may be a wider discussion on whether Article 2 is engaged in the inquest. There are certain inquests where Article 2 is automatically engaged like a police shooting and self-inflicted or violent deaths in detention (whether police, prison, under a mental health section, immigration detention). The Article 2 argument is more complicated if the death occurred in the community, in hospital if not under a section or if the medical cause of death was a “natural” one. This is an important issue as it will determine how wide the inquest will be, whether funding is available for the inquest and the type of conclusion that can be left.

Inquest Fact What Is Article 2?

Article 2 is the human right that says the State (UK) has to respect the ‘right to life’. It says the state should not cause death, should have systems to prevent or reduce the risk of death and should investigate when the state has done something or not done something that might have contributed to a person’s death.

The next step would be to meet with your lawyer and Barrister (if one is instructed). At this conference we will discuss how we expect the inquest to proceed, issues of concern, what will likely come out in the evidence and the likely conclusions.

Inquest Fact

Did you know that before the law changed in 2013 an inquest conclusion was called a “verdict”.

There are two types of conclusions that can be recorded at the end of an inquest – a short form (unlawful killing, lawful killing, open conclusion, suicide, accident, to name but a few) and then a narrative conclusion. A narrative conclusion in a non Article 2 Inquest should be a brief, neutral, factual statement and should not express any judgement or opinion. If however the Inquest engages Article 2, they must record ‘in what circumstances the deceased came by their death’, and it can be judgemental.

The Inquest will normally take place in person in the Coroners Court. The length of the final inquest will vary depending on the issues to be explored, whether there is a jury and how many witnesses are listed to give evidence.

Evidence from the various witnesses will be heard and at the conclusion of the evidence the lawyers will make a number of legal submissions as to what conclusions can be recorded on the Record of Inquest.

Inquest Fact

Did you know….?

The Coroner needs to answer four questions at an inquest

1) Who the deceased was
2) When they died
3) Where they died
4) How they died

The answers to these questions will be recorded on a document called the Record of Inquest which will then be used by the Registrar to record the death.

Our inquest solicitors will advise you on the various options that might be open to you following an inquest including

• whether you could bring a civil claim if failings have been identified that are causative to the death
  whether a Prevention of Future Deaths Report is to be prepared by the Coroner and what this entails re learning lessons