Inquests


The right to an inquest

An inquest must be held in those circumstances where a Coroner is informed that the body of a person is lying within his or her district and there is reasonable cause to suspect that the individual died:
  • A violent or unnatural death or
  • A sudden death of which the cause is unknown or.
  • In prison or in such circumstances as to require an inquest under any other Act.
The Coroner only has a right to hold an inquest if one of these conditions is satisfied. Conversely, the Coroner cannot decide not to hold an inquest if one of the conditions is satisfied.

The duty to conduct an inquest does not extend to the death of a non-viable foetus or a stillborn infant, which did not breathe or show any other sign of life. If however an infant lives, even shortly, there is a right to an inquest in relation to his or her death. If there is any question about whether the infant was ever alive, the Coroner should treat this as a preliminary issue. If the Coroner concludes that the infant died before life independent of its mother, the death will be registered as a stillbirth in a similar way to that had there been a live birth.

In some cases only parts of a body are discovered within the Coroner’s district. In these circumstances the Coroner will consider whether it is reasonable to assume that the tissue or body parts came from a dead body. The mere fact that parts of the body have been found does not necessarily mean that a death can be assumed.

If human remains do not constitute ‘a body’ or if no body exists (the body may have been cremated) but the Coroner has reason to believe that a death occurred in or near his or her district and the circumstances are such that an inquest would be held if there was a body, he or she should report the matter to the Secretary of State who may consider directing an inquest into the death.

An unnatural death

An ‘unnatural’ death has been defined as one where there is suspicion of foul play, wrongdoing including negligence, or some peculiarity other than natural illness. In one case the Court of Appeal held that a woman’s death could be regarded as unnatural after her blood pressure was left unmonitored following a caesarean section delivery, such that the opportunity to provide effective treatment was lost: R v HM Coroner for Inner London North ex parte Touche. The court held that where a person is suffering from a condition which if not monitored and treated in a routine way will result in death and that treatment or monitoring is omitted, the Coroner must hold an inquest unless he or she can say that there are no grounds for suspecting that the omission was an effective cause of death.

A violent death

A death may be considered ‘violent’ where a person is fatally injured, intentionally or accidentally. Road fatalities fall under this heading, as do other ‘accidental’ deaths, such as those that occur due to some accident at work, and will trigger an inquest into the death. Also, if there is reasonable cause to suspect that the deceased took his or her own life an inquest will be held.

A sudden death with the cause unknown

If the death is unexpected and either the terminal cause of death or the underlying condition is unknown an inquest will be held. In these circumstances the Coroner has the right to order a post mortem examination and if this reveals conclusively that the death was natural, the Coroner need not hold an inquest, so long as none of the other statutory requirements to hold an inquest applies.

A death in custody


If the death occurred whist the deceased was detained in prison the Coroner must hold an inquest. The term ‘prison’ is not defined and it is arguable that it extends to situations where the deceased person is restrained or deprived of his or her liberty, for example, if the deceased person died whilst detained at a police station or under the provisions of the Mental Health Act 1983 (MHA). The Home Office Circular 35/69 recommends that Coroners should hold an inquest into the death of a person in any kind of legal custody.

Deaths outside England and Wales

Where a person dies outside England or Wales, the Coroner must still hold an inquest if the dead body comes to lie within his or her jurisdiction and if the circumstances of the death require it. The Coroner with jurisdiction is usually the Coroner for the district of the intended burial or cremation of the deceased. If the death has been the subject of an inquiry outside England or Wales the Coroner may be assisted by documents or reports that were available for those proceedings, in which case the inquest may be significantly shortened by reading, rather than hearing, witness evidence (if there is no objection – see ‘Evidence at the Inquest’ below).

Adjournment for criminal trial

If a person has been charged with murder, manslaughter or infanticide, causing death by dangerous driving, causing death by careless driving under the influence of drink or drugs; or aiding, abetting, counselling or procuring the suicide of the deceased, the Coroner will adjourn the inquest until after the criminal proceedings have ended unless the Director of Public Prosecutions informs the Coroner that it is unnecessary. If, during the inquest, the coroner believes forms the opinion that a person might be charged with one of these offences he or she must adjourn and send the prosecuting authorities details of the evidence.

After the conclusion of the criminal proceedings the Coroner may resume the inquest if there is sufficient cause. If the Coroner does not resume the adjourned inquest, he or she will send a certificate to the registrar of deaths stating the results of the criminal proceedings. If the Coroner does resume the inquest, the findings of the inquest are not permitted to be inconsistent with the outcome of the criminal proceedings. In some (rare) cases the criminal proceedings may identify that the deceased was unlawfully killed, which would be sufficient for the coroner to simply record the cause of death, but because of the wider circumstances surrounding the death requiring examination, the coroner will be obliged to hold an inquest looking into these issues. For example, in one case where a person had been found guilty of the deceased’s murder in criminal proceedings, the court held that an inquest was nevertheless required to enquire into potential failures of the state authorities to take steps to protect the deceased where it was alleged they knew him to be at real and immediate risk of violence from the perpetrator.

The purpose and scope of inquests


An inquest is inquisitorial, rather than adversarial. This means that there are no opposing parties each trying to prove their case. The sole purpose of the inquest is to determine as far as possible the identity of the deceased and where, when and how he or she came to die. These findings are then recorded on the inquisition form at the conclusion of the inquest. The inquest is not a mechanism for apportioning blame for the death. Indeed, the verdict at an inquest must not be expressed in such a way as to appear to determine criminal liability on the part of a named person or civil liability. For example in the case of road traffic accidents, the Coroner will inquire into whether the death was accidental but will not seek to determine who, if anyone, bears responsibility for the accident.

The Coroner has a duty however to hold a sufficiently wide enquiry to determine how the deceased died. The question of ‘how’ a person died is not limited to establishing merely the medical cause of death and may require a critical examination of the circumstances in which the death occurred. In certain circumstances this will mean enquiring into whether any lack of care actually contributed to the death. In the example of a road traffic accident, the coroner will not be concerned with determining whether another driver was careless, but will merely be concerned to establish that the death was accidental. However, if the deceased was dependent upon some form of care (for example at a hospital or in a residential nursing home) and there is a suggestion that such care was not provided, the coroner should enquire into whether a gross failure to provide care (see below) caused or contributed to the death. The coroner should also enquire into any suggestion that the death was caused by another’s act, for example, if medical treatment the deceased was receiving might have caused or contributed to the death.

European Convention on Human Rights

In certain circumstances the scope of the inquest may be enlarged to enable the state to comply with its duties under the European Court of Human Rights (ECHR) to effectively investigate deaths. These duties arise from Article 2 of the ECHR, which protects an individual’s right to life. The European Court has held that the obligation to safeguard the lives of those within its jurisdiction imposes a duty upon the state to put in place an effective official investigation where there is reason to suspect that the death was in contravention of Article 2. An enhanced investigation will certainly be required where an individual dies as a result of the infliction of lethal force by state agents (such as police or army officers) or whilst under the care or protection of the state (for example prisoners or individuals known to authorities to be at real and immediate risk of harm). The English courts have held however that where a person is merely under the care of National Health Service staff and the only concern is in relation to how clinicians exercised their clinical judgment, an enhanced investigation will not be required by the coroner in order to discharge the state’s obligation under Article 2. If some state policy or system failure contributed to a death (whether in an NHS hospital or elsewhere) this in itself may trigger the need for the enhanced investigation.

If an enhanced inquest is required, there are certain minimum requirements for the investigation, which the coroner should have in mind; they are that the inquest should be independent, effective, reasonably prompt, involve a sufficient element of public scrutiny, and involve the next of kin to the extent necessary. An important feature is the ability of the deceased’s family to participate in the proceedings. In order to ensure that the family is able to participate effectively, it will sometimes be necessary for relatives to have legal representation. There is now provision for legal aid funding which is available for families to obtain representation at inquests and in certain limited circumstances the eligibility criteria for funding may be waived. It is also important that the coroner or jury has the ability to formally and publicly record any findings of failure on the part of the responsible state agencies that caused or contributed to the death. In such circumstances the coroner or jury may record as part of the verdict any such failures.

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