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
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.