Coroner's Inquest

If you are the family member of someone who has died and you have been informed that there needs to be an inquest into their death, this can be a daunting and confusing time. You probably have a lot of questions, not just about how it happened, but also what to expect from the inquest process.

In certain circumstances when a person dies a death certificate cannot be issued until an investigation has been carried out to establish the facts necessary for the certificate to be finalised. The person who carries out such investigations is called a Coroner. Coroners have what is called ‘jurisdiction’ over geographical areas so the Coroner who has charge of a particular investigation will depend on where the person in question has died.  Coroners are appointed by Local Authorities and they are either legal or medical professionals.

A Coroner must investigate a death in his/her jurisdiction if there is reason to suspect that:

1. The death is violent or unnatural

2. The cause of death is unknown

3. The death occurred whilst the deceased person was in custody (such as a prison, police cell or psychiatric hospital)

The Coroner needs to establish through his/her investigations who the deceased person was, when they died, where they died and how they died.

The enactment of the Human Rights Act 1998 made it unlawful for the state to act in a way that infringes rights provided by the European Convention on Human Rights (ECHR), including Article 2 of the ECHR (the right to life). Article 2 imposes obligation on the state not to be complicit in the taking of life (systemic duty) and to have systems in place to protect life (operational duty). There is also a procedural duty to investigate where a death may have resulted from a breach of the systemic or operational duty. If it is decided that the inquest engages Article 2 then the Coroner will investigate not only how the deceased person died, but also investigate in what circumstances they died.

At an inquest there are parties called ‘Properly Interested Persons’ (PIPs) who take an active role in the process- they often include family members of the deceased, representatives of the establishment where the death died (if in custody at the time of death) and those who were directly involved in the care of the deceased. It is normal for PIPs to be legally represented and through their representatives PIPs can receive information from the Coroner prior to the inquest (known as disclosure), receive directions from the Coroner, ask questions of witnesses at the hearing and submit legal arguments to the Coroner about any point of law that may arise.

Inquests are not usually heard in front of a jury; however there are cases in which it is mandatory. This is the case if the death occurred in the custody of the state and one of the following also applies:

1. The death was violent or unnatural, or of unknown cause

2. The death resulted from an act or omission of a police officer or member of a service police force in the purported execution of their duties

3. The death was caused by an accident, poisoning or disease which must be reported to a government department or inspector

The Coroner does have discretion to call a jury where he/she feels that it is necessary in the wider public interest.

What is a pre-inquest review?

Sometimes it is necessary for the Coroner to hold a hearing before the Inquest which the PIPs attend called a Pre Inquest Review Hearing (PIR). The purpose of the PIR is to determine issues before the inquest which will have an impact on how the hearing in held, such as whether Article 2 is engaged and what issues the inquest will address (also known as ‘scope’). The PIPs may need to make representations to the Coroner about what witnesses will be required to attend at court and to determine whether any further witness statements or records need to be obtained and disclosed. Practical issues such as witness availability and time scale for the hearing may also be addressed. PIR hearings can be an important part of the inquest process as many of the important issues will be decided before the inquest hearing itself begins.

What Happens At The Inquest?

The lay out of Coroner’s Courts do vary but they tend to look like an ordinary court room inside. The Coroner will sit at the front of the room and the legal representatives will sit on benches facing him/her. If there is a jury they will normally be seated to one side of the room so that they have a clear view of the witness box, the legal representatives and the Coroner. Family members of the deceased will normally sit behind the legal representatives.

The inquest is an inquisitorial process rather than an adversarial one; this means that it is an investigation not a trial with contested opponents. The Coroner and/or Jury will hear evidence from live witnesses who attend at court and also may be read witness statements from witnesses who are not present. When a live witness gives evidence the Coroner will begin by asking them questions, then the legal representatives for the PIPs are permitted to ask relevant questions to assist the Coroner’s enquiry. If there is a jury present they are also permitted to ask questions of the witness.

Once the Coroner has heard from all of the witnesses in relation to the circumstances of the death, the Coroner is then able to call witnesses to address any concerns that have arisen that might give him/her cause for concern that there is a risk of further deaths occurring in the same establishment or in similar circumstances.

This is often referred to as Regulation 28 evidence, as it relates to the coroner’s power under Regulation 28 of The Coroners (Investigations) Regulations 2013, which allows him/her to publish a report on any such issues that have arisen. The Coroner is duty bound under the Coroners and Justice Act 2009 to make such a report, if he/she believes that action is required to reduce or prevent the risk of further deaths that has been identified.

At the end of an inquest a conclusion must be reached in relation to the death. If there is a Jury the Coroner will hear legal arguments from PIPs in their absence as to what conclusions should be left for the Jury to consider. Possible conclusions should only be left to the Jury if they are supported by the evidence that has been heard. If there is no Jury the PIPs will address the Coroner on what conclusions it would be appropriate for the Coroner to reach.

Possible conclusions include:

• accident or misadventure (the unintended consequence of an intentional act)

• alcohol/drug related

• industrial disease

• lawful killing

• unlawful killing

• natural causes

• open conclusion

• road traffic collision

• stillbirth

• suicide

The Coroner or Jury may also be in a position to return a narrative conclusion. This means that they produce a paragraph which factually describes the circumstances of the death. Narratives cannot name any individuals or use words or phrases which apportion civil or criminal liability but they can be used to make wider comments on any failings or issues which have been raised during the Inquest.

The inquest ends with the coroner/jury completing a Record of Inquest and reading out their conclusions, followed by the coroner giving his/her determination as to whether there will be a Report to Prevent Future Deaths.

Losing a loved family member is extremely distressing, please do get in touch for help.

Chambers and Partners 2021

"He's exceptionally talented and an extremely able barrister due to his grasp of the law and sensible approach to the jury. He can outshine leading silks on his day."

Chambers and Partners 2020

Highly sought after for his calm and collective approach which is never anything but measured. He is well received by clients, fellow professionals and the judiciary.” “He is meticulous in his preparation and presents his cases well before the court.”

Legal 500 2020

“He is a particularly strong junior in serious crime and fraud. He has dry wit that can wither any hostile witness testimony with ease. He has a huge practice nationally in complex crime. A very safe pair of hands”

Legal 500 2019

Has a great eye for detail”

Legal 500 2018

“Advises on serious financial crime matters. Regularly defends cases of mortgage, tax and investment fraud”

Chambers and Partners 2017:

“Recognised for advising on serious financial crime matters. He regularly defends cases of mortgage, tax and investment fraud ….His written work is particularly good."

Legal 500 2016:

‘His calm persona can cut through complex issues with ease’.

Chambers and Partners 2016:

‘Particularly noted for his expertise in cartel investigations, insider dealing and rate fixing matters. He routinely represents large corporations and individuals’

Legal 500 2015:

‘…often has the prosecution running around in circles’

Chambers and Partners 2015:

Has a nationwide financial crime practice and is regularly instructed to defend in complex fraud cases…….has an A to Z knowledge of fraud work."

Legal 500 2014:

‘An excellent jury advocate’

Chambers and Partners 2014:

‘Has a practice encompassing mortgage, tax and insurance fraud cases.

Legal 500 2013:

mindblowingly experienced'

Chambers and Partners 2013:

praised for his ability to handle cases which combine civil and criminal fraud elements. He has a national fraud profile, and handles mortgage and insurance frauds, money laundering matters and MTIC cases’ 

Chambers and Partners 2012:

‘a diligent professional acclaimed for his fantastic knowledge of his subject’

Chambers and Partners 2011:

'fights really hard for his clients and is very good tactically’

Legal 500 2011:

‘is comfortable with any level of tribunal and is completely au fait with complex legal issues’

Legal 500:

‘is widely experienced in fraud…has good experience in conspiracy trials’

Legal 500:

‘has a serious crime practice for his call and good experience in fraud and conspiracy trials’

Legal 500:

‘has a busy serious crime practice’

“I am delighted with the verdict. I am an innocent man and I’m glad the jury believed in me. This has been a very difficult time for me. My reputation was badly damaged after my arrest but now I can get on with my life as an innocent man with my head held high. I would like to take this opportunity to say I am especially indebted to my Barrister, Mr Ashraf Khan. Without his support I would have been lost”

QM, acquitted after a 5 month sexual abuse trial.

I cannot describe how happy I am today. Thank you Ashraf for all your help through this difficult period in my life. I was so scared I would loose my livelihood. I owe you so much”

TH, an independent financial adviser, acquitted after a 4 month fraud trial.


“I am delighted with the verdict! Thank you so much”

DO, acquitted of Grievous Bodily Harm after a trial.


“Brilliant result, thanks so much! Thank you for all the hard work and taking the time to understand our case; our previous lawyers just didn’t want to know”.

GH, acquitted of large scale drugs conspiracy.



“Thank you for everything! I could have spent my whole life in prison for something I didn’t do!

LW, acquitted of gang related murder after a 10 week trial.



“Thank you Mr Khan for all your hard work during this long and difficult trial. We knew we could always rely on you. You were superb!”

DM, acquitted of large scale drugs conspiracy.