An Inquest is a fact finding exercise
held in public in front of a coroner (or a coroner and a jury) to determine the cause
of violent or unnatural deaths.

The bereaved (or their representatives) and other relevant parties can ask questions of the coroner. It is not a process in which criminal culpability or civil negligence is established, though the evidence that is heard at an inquest and the verdict returned by the coroner or jury may facilitate in the process of determining both those issues.

This section of the website allows you to find out more about the purpose of an inquest, how it operates, the rights of the bereaved and other parties, and the possible verdicts that can be returned.

There are two main pieces of legislation setting how coroners courts and inquests operate. The Coroners Act 1988 and the Coroners Rules 1984

Government Review of Coroners Courts
The Coroners Review has published a consultation document. It is proposing that there will no longer be an automatic right for families to have an inquest into work-related deaths. To see what the inquiry says about work-related deaths, Click Here

To download the whole document, Click Here

To see CCA’s preliminary views on the Coroner's Review consultation document, click here

To see CCA press release, Click Here

Back to the Top

Purposes of the Inquest
This is set out in section 36 of the Coroners Rules:

-

The key question is what does "how" mean and in particular how widely is it be defined. This is a crucial question. It will decide what witnesses are called, how senior a company manager can be called, is it possible to argue that a company director should give evidence, what questions will be permitted.

A judge in a 1994 case stated:

"Although the word "how" is to be widely interpreted, it means "by what means" rather than "in what broad circumstances", In short the inquiry must focus on matters directly causative of death and must indeed by confined to these matters alone."

The judge went on to say

"the question of how the deceased came by his death is of course wider than merely finding the medical cause of death and it is therefore right and proper that the coroner should inquire into acts and omissions which are directly responsible for the death …

Once an inquest is held, the duty to inquire into "how the deceased came by his death" requires one then to take a broader view and investigate not merely the dominant cause but also … any acts of omission which are directly responsible for the death."

This would appear to suggest that any witness who can given evidence on any conduct that is possibly a direct cause of the death, should be allowed to give evidence.

This in itself raises questions about what is a "direct cause of the death"

It should though be noted that:

"it is not the function of a coroner’s inquest to provide a forum for attempts to gather evidence for ... future criminal or civil proceedings"

Back to the Top

Implications of Rule 42 on what is meant by "how"
Rule 42 of the Coroners Rules states that

"No verdict shall be framed in such a way as to appear to determine any question of:
(a) criminal liability on the part of a named person, or
(b) Civil Liability"

It is often suggested that this rule may conflict with a wider interpretation of "how". A case has however decided that any conflict must be resolved in favour of ensuring that there is a proper inquiry:

"Such conflict as may in any given circumstances appear to arise between [rule 42] and the duty to inquire ‘how’ must be resolved in favour of the statutory duty to inquire, whatever the circumstances of this may be"

It needs also to be noted that rule 42 only relates to the ‘wording’ used in the verdict not in the nature of the inquiry.

"It may be accepted that in a case of conflict the statutory duty to ascertain how the deceased came to his death must prevail over the prohibition in rule 42. The scope for the conflict is small. Rule 42 applies and applies only, to the verdict. Plainly the coroner and the jury may explore the facts bearing on criminal and civil liability. But the verdict may not appear to determine any questions of criminal liability on the part of a named person nor any question of civil liability"

In practice, therefore, rule 42 can be respected by simply the omission of a name.

Back to the Top

Coroners’ Power
There are not many rules determining the procedure of an inquest and it is very much up to the coroner to decide how an inquest should proceed:

As one judge has stated:

"It is the duty of the coroner as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the relevant facts are fully fairly and fearlessly investigated … HSE fails in his duty if his investigation is superficial, slipshod or perfunctory. But the responsibility is his. He must set the bounds of the inquiry. He must rule on the procedures to be followed"

Back to the Top

Witnesses and questions
It is the coroner who decides:
• who shall be called as a witness and
• what questions can be asked.

Rule 20 of the Coroners Rules states that the:

"the coroner disallow any question which in his opinion is not relevant or is otherwise not a proper question."

It states that the following people can question witnesses:

Pre-inquest Disclosure
There is no obligation on the part of the coroner to provide advanced disclosure of witness statements or other evidence.

Some are willing to provide documents if asked, other are not

In fact there is no obligation to even provide a list of witnesses. Usually, however, coroners are willing to provide this when requested

Back to the Top

Other Procedural Rules

Back to the Top

Summing up by the coroner and Verdicts
Rule 41 states:

"Where the coroner sits with a jury, he shall sum up the evidence to the jury and direct them as to the law before they consider their verdict and shall draw their attention to rules 36(2) and 42"

The coroner will only leave - as options for the jury to return - those verdicts that s/he considers appropriate as a matter of law are justified by the evidence and safe for them to return.

There is no definitive list of verdicts. Schedule 3 of the coroners rules simply suggest some possible verdicts
• natural causes
• industrial disease of
• dependent on drugs
• want of attention at birth
• killed himself
• accident/misadventure
• killed lawfully
• open verdict
• unlawfully killed (murder manslaughter or infanticide)

For a verdict of "suicide" or "unlawful killing" the jury must be satisfied"beyond reasonable doubt" (i.e. sure)

For all the other verdicts, the jury must be satisfied "on the balance of probabilities" (i.e. more probable than not).

Back to the Top

Government Responsibility for Coroners
There are a number of different Government Departments with responsibility for Coroner's courts.
• The Home office has general responsibility for the coroner service;
• Local Authorities are responsible for the resourcing of coroners
• Lord Chancellor makes the 'coroners rules' which set out guidelines for how Coroners courts operate
• Attorney General has the power to to allow an application to be made to High court for new inquests

Back to the Top

A new book on inquests for Lawyers
Legal Action Group books published a book on "Inquests - a practitioner’s guide" on 1 October 2002. It is written by Leslie Thomas, Danny Friedman and Louise Christian. For further details contact 020 7833 7424. To download a flyer, click here (for word) or here (for PDF)