|
Immediately
after the death
If the coroner decides to to hold an inquest, s/he
will
| • |
organise a post-mortem |
| • |
"open"
the inquest, a few days after the death, to identify
the person who has died and to hear some basic
evidence about how the person died; |
| • |
adjourn
the inquest; |
Investigation by the police and regulatory bodies
During this period of adjournment, investigations
by the police and regulatory bodies will continue
to take place. These investigations are concerns with
determining whether any criminal offences have been
committed by organisations or individuals.
To read about how the police and HSE should investigate
a work-related death, Click
Here
Completion
of investigation
If, when the investigation is over and (a) the Crown
Prosecution Service decides not to prosecute for manslaughter
and (b) the HSE or local authority have completed
its investigation, the Coroner will receive a copy
of any statements taken by the HSE/police and their
reports. If the Crown Prosecution decides to prosecute
for manslaughter, the inquest will then be adjourned
until after the inquest and may or many not be resumed.
(To read about whether an inquest will be resumed
after a manslaughter prosecution, click here).
Organisation
of inquest by Coroner
When the coroner has received all the information
from the investigation bodies, s/he will then:
• set a date for a full inquest;
• summon witnesses.
There
may before this be what is known as a 'pre-inquest
meeting' at which the coroner will discuss with the
parties what issues the coroner considers should be
subject to the inquest, which witnesses s/he intends
to call and what information prior to the inquest
s/he will disclose.
It
is for the coroner to make the final decision which
witnesses to call and how broad the inquest should
be at looking at the causes and circumstances of the
deaths. To read about the
purpose of an inquest and how broad an inquest should
be, click here
Prior
to - and indeed during - the inquest, the parties
can make submissions to the coroner in relation to
the witnesses and the breadth of the inquest and it
is possible for coroners' decisions on these (and
other issues) to be subject to judicial review. To
read about challenging decisions by coroners, click
here.
If
there is no pre-inquest hearing, the coroner will
usually inform the bereaved family by letter about
who will be called as witnesses
Jury
Most inquests into work-related death will be heard
in front of a jury - though this is not always the
case. To read about this click
here.
Witnesses
In relation to work-related deaths, any immediate
eyewitnesses of the death will always be called to
give evidence as well as the inspector from Health
and Safety Executive, Local Authority, or other regulatory
body. A member of the bereaved family member is usually
always asked to give evidence at the beginning of
the inquest to give some brief information about the
person who has died.
At the Inquest
| • |
the
coroner will call each witness in turn. S/he will
then ask questions. |
| • |
after
the coroner has concluded his/her questions, all
the other interested parties – including
the family of the bereaved – can also ask
the witness questions. The coroner can decide
that a particular question can not be asked because
in his or her view it goes outside of the parameters
of the inquest. The coroner can also advice a
witness that s/he has a right not to answer particular
questions that could incriminate the witness (click
here for more on this. ) Jury members can also
ask questions. |
| • |
at
the end of the inquest the lawyers representing
the parties may then make a submission concerning
which verdicts should be left for the jury to
consider. |
| • |
the
coroner will then summarise the evidence and inform
the jury about what verdicts they have an option
of returning. The coroner will the explain legal
test that determine whether a particular verdict
is appropriate. For Work-related deaths, this
is usually "accidental Death" or "unlawful
killing", though see the section on verdicts. |
| • |
the
jury will return a verdict. |
Impact
of Unlawful Killing verdict
If a verdict of 'Unlawful Killing' is returned by
a jury - which is not a common situation - the case
is referred to the Crown Prosecution Service for it
to consider whether or not to prosecute for manslaughter.
If
new evidence emerges at the inquest, the police or/and
the Health and Safety Executive may initiate new investigations
If not, the HSE or Local Authority will decide whether
or not to prosecute a company or individual for a
health and safety offence. To read more about health
and safety offences, Click
Here
Section
8(2) of the Coroners Act 1988 states that the task
of the jury (if one has to be summoned - is to ‘inquire
as jurors into the death of the deceased’ and
they are sworn ‘diligently to inquire into the
death of the deceased and to give a true verdict according
to the evidence’
Section
11(2) of the Act states that the coroner is to ‘examine
on oath concerning the death all persons who tender
evidence as to the facts of the death and all persons
having knowledge of those facts whom he considers
it expedient to examine’.
Sectin
11(3)(a) states that, the jury, where there is one,
must hear the evidence and give their verdict, whilst
section 11(5) requires that the inquisition, which
should be signed by the jury or a majority of them,
must set out in writing, so far as such particulars
have been proved, and in such form as the Lord Chancellor
may by rule prescribe, ‘(i) who the deceased
was; and (ii) how, when and where the deceased came
by his death’.
Rule
43 provides:
‘A coroner who believes that action should be
taken to prevent the recurrence of fatalities similar
to that in respect of which the inquest is being held
may announce at the inquest that he is reporting the
matter in writing to the person or authority who may
have power to take such action and he may report the
matter accordingly.’
s
11(6) of the Act provides:
‘At a coroner’s inquest into the death of
a person who came by his death by murder, manslaughter
or infanticide, the purpose of the proceedings shall
not include the finding of any person guilty of the
murder, manslaughter or infanticide; and accordingly
a coroner’s inquisition shall in no case charge
a person with any of those offences.’
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:
|
• |
a
parent, child, spouse, and any personal representative
of the deceased; |
| • |
any
beneficiary under a policy of insurance issued
on the life of deceased |
| • |
the insurer who issued such a policy of insurance; |
| • |
any
person whose act or omission or that of his agent
or servant may in the opinion of the coroner have
caused or contributed to the death of the deceased; |
| • |
any
person appointed by a trade union to which the
deceased at the time of his death belonged, if
the death or the deceased may have been caused
by an injury received in the course of his employment
or by industrial disease |
| • |
an
inspector appointed by, or representative of,
an enforcing authority, or any person appointed
by a government department to attend the inquest |
| • |
the
chief officer of the police |
| • |
any
other person who in the opinion of the coroner
is a properly interested person |
Back to the Top
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
| • |
The
Coroner must inform any person "whose conduct
is likely to be called into question at the inquest"
that the inquest is going to take place. Although
usually such a person will have been called to
give evidence at the inquest |
| • |
A
coroner can, if s/he so wishes sit with an assessor.
Sometimes, for example, an HSE inspector does
not actually give evidence, but sits with a coroner
to assist him in asking questions etc. |
| • |
A
person can refuse to answer a question which may
incriminate himself. Rule 22 states:
| (1) |
No
witness at an inquest shall be obliged to
answer any question tending to incriminate
himself |
| (2) |
Where
it appear to the coroner that a witness
has been asked such a question the coroner
shall inform the witness that he may refuse
to answer. |
|
| • |
Lawyers
can not make submissions as to the "facts"
of the case. They can however make submission
on points of law – and in particular on what
verdicts the coroner should leave to the jury |
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)
|
