An inquest is a public court hearing to establish who has died, and how, when and where the death happened. A coroner must hold an inquest if it was not possible to find the cause of death from the post-mortem examination, if the death is found to be unnatural, occurred in prison, police custody or in hospital, or if the coroner thinks there are grounds for further investigation. The inquest may be held with a jury, depending on the circumstances of the death. It is not a trial and its purpose is to discover the facts of the death, not to apportion blame. The main inquest hearing should normally take place within six months or as soon as is practical after the death has been reported to the coroner. Some cases are more complex and the wait is longer.
The coroner is required to start the process as soon as possible and this is known as ‘opening an inquest’. This is usually a brief meeting in the coroner’s court, allowing them to ‘adjourn’ (postpone) the full inquest to a later date to allow sufficient time for information to be gathered. You are entitled to attend both the initial and the full inquest and the next of kin will be informed of the date.
Most inquests are open to the public so other people, including the media, can be there. You do not have to attend – unless the coroner wants to call you as a witness. Many people do not attend the first, brief hearing but do attend the full inquest. The coroner’s officer will be able to discuss this with you. If you do wish to attend, it may be possible for you to visit the courtroom before the inquest begins so you can be familiar with its surroundings.
Reaching a conclusion
After hearing the evidence, the coroner will make the ‘finding of fact’ (who the deceased was, when and where they died and the medical cause of their death) and the ‘conclusion’ (about how the person came by their death). This may be one of several conclusions and all have to be established ‘beyond reasonable doubt’. The most common are:
– ‘suicide’ (when the coroner is sure that the person intended to take their own life) – ‘open’ (when the cause of death cannot be confirmed and doubt remains as to how the death occurred)
– ‘accidental or misadventure’ (where the person died as a result of actions by themselves or others that went wrong or had unintended consequences)
– ‘narrative’ (when the coroner feels the other conclusions are not right for these circumstances and sets out his or her understanding of the facts).
The conclusion of the coroner can be difficult to accept or it can come as a shock. Some people, fully aware that the person took their own life, are confused when the conclusion is ‘open’ – it may make it harder to talk about what you believe happened. Others may be relieved to have an ‘open’ or ‘accidental’ conclusion. Some may find a conclusion of suicide distressing. A narrative conclusion may feel inconclusive. You can ask for a copy of the post-mortem investigation report and any other documents used during the investigation. These reports are detailed and you may find them distressing. You may want to ask a friend or someone close to go through them in the first instance. For a fee, you can also ask for a recording of the inquest, or a transcript of what was said.
Sometimes an inquest will show something could be done to prevent future deaths. If so, the coroner must write a report drawing this to the attention of the organisation or person that may have the power to take action. The organisation must respond within 56 days, stating what action it has taken. These reports are sent to the Chief Coroner and published electronically. There are clear guides to the inquest process on www.gov.uk, as well as information on how to register a complaint or lodge an appeal if you are unhappy with any aspect of the process. If the person died while under the care of mental health services If the person died while an in-patient or whilst under the care of a community team, then mental health services are likely to offer their support. There will be an investigation (sometimes called a Serious Incident Requiring Investigation, a Serious Untoward Incident, or similar) running alongside the coroner’s inquiry. The aim will be to find out if the death could have been prevented and to learn for the future. A member of the mental health services team should make contact with you and ask for your views to be added to the investigation. You should be kept fully informed throughout the process, unless you ask not to be, and there should be an identified person you can contact if you have questions or concerns. You may want to have your own legal representative at the inquest, so you have someone who can guide you through the process, give you advice and ask questions. Having a legal professional can also be valuable if you want to challenge any decisions made or if you are considering a compensation claim.
If the person died in prison or in detention If the person died while being detained, there will be an investigation into what happened and whether they received appropriate care. This may mean that you speak to officials from the Prison Service as well as the coroner’s officer. You will almost certainly be assigned a Family Liaison Officer from the prison staff who will tell you what has happened and make arrangements for you to visit the prison or police cell if you wish. You may want to have your own legal representative present at the inquest.
When the death occurs away from home
The investigation, post-mortem investigation and inquest all take place in the area where the person died, not where the person comes from or lives. This may be difficult as it will mean that you will have to travel to the inquest. If you are the next of kin, the coroner’s officer will do their best to help you understand what is happening and when. It can also be a little more complicated and expensive to arrange for the person’s body to be brought ‘home’ for the funeral, and even more complicated if the death happens in another country. There is helpful information on www.gov.uk.