Coroners' Court

Coroners' Courts deal with hearing of evidence at an Inquest conducted by a Coroner who is an Officer appointed by the King. 

We explain the process and more about Inquests below.  However, you can find the government guide for the bereaved here.

An inquest is not conducted like a civil trial would be, it establishes the identity of the deceased; how, where and when the death occurred.  It does not however establish who was responsible for the persons death, this would be dealt with in civil or criminal courts.

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We know that dealing with the loss of a loved one is a very painful and emotionally exhausting process, and then being faced with an Inquest into their death can be harrowing, even more so if you have no legal representation.  Unfortunately, legal aid is only available to fund legal representation at an inquest in very limited circumstances, such as deaths in custody and in some cases of mental health care.

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We provide legal assistance and representation to help you and to put questions at the Inquest on your behalf.  Our founder Director, Patricia White is a Member of the Lawyers Group for the charity INQUEST where you can also find helpful guidance and information, the link is here.

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We provide initial advice for no charge and assess your financial means to then agree with you a reasonable and affordable fee that matches your budget.

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What do you need to do and who do you contact?

The first starting point is to make contact with the Coroner’s office who will provide you with details of who is the assigned Coroner's officer to the case who will be involved throughout the process leading up to the inquest hearing itself.  It can be quite a lengthy process for the Coroner to deal with due to the volume of documents and enquiries to be made, so it can take time for information to be relayed.  You will be able to get regular updates from the Coroner's officer regarding gathering relevant documentation such as the post-mortem report and any witness evidence.  

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Since the Covid-19 pandemic, the Coroners' courts have become much busier with the likelihood that cases will experience considerable delays.  Although it is usual that an inquest should be held within six months of the date of death, many inquests are listed outside of the six-month time period.

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It is important that the Coroner has all the relevant information as soon as possible for them to be able to release relevant documentation to the parties before the Inquest starts.  The Coroner's officer will provide all the documentary evidence which the Coroner intends to use and refer to at the Inquest, however, it is important that this is requested in good time.

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The documents usually include:

• the post-mortem report and any toxicological reports,

• the medical records and some form of police report if the police were involved.

• the witness evidence and list of witnesses

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We can assist you with reviewing the evidence and going through the witness evidence to prepare questions for those giving oral evidence in court.  If you think there is a witness who should give evidence who is not on the list, or who is on the list but is not down to give oral evidence, then it should be raised with the Coroner’s officer.

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What is the procedure?

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Since COVID 19, more often than not once the inquest has been formally opened for the Coroner to begin their enquiries, they may decide to hold a review sometime before the actual inquest takes place. This will usually be the case where the inquest is likely to last at least a day, and where there is a large amount of documentation.

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The purpose of the review is for the Coroner to finalise the witness evidence and decide who will be called to give oral evidence.  They will also define the 'scope' of the inquest and the documentation that will need to be included in an inquest bundle. There will be no evidence heard at the review stage. 

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At this hearing whether Article 2 is engaged may also arise as a question to be addressed.  Article 2 is the ‘right to life’, and this says that the state (i.e. the UK), should not cause death, and should have systems to prevent or reduce the risk of death and should investigate when the state has done something or not done something that might have contributed to a person’s death.

Article 2 is automatically engaged where for instance there has been self-inflicted or violent deaths in detention, which could be whilst in police custody, in prison, under a mental health section, or even immigration detention. If the death arose from complicated circumstances this will be a determining factor, as to whether funding is available for legal representation at the Inquest.

We can assist with reviewing the documentation at this stage and help to put forward any arguments for who should be called to give witness evidence, and to also check if there is any other relevant documentation that could be missing.  Although the review is usually relatively informal, it is still part of the process of preparing for the full inquest hearing and will give you an opportunity to meet the Coroner, and to see inside the court itself, if it is to be an in person Inquest.  If the review and the full Inquest is dealt with remotely, you will have the opportunity to familiarise yourself with the process, and gain an idea of what to expect.  There is guidance from the Chief Coroner on remote hearings here. 

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After the review has taken place the coroner will set the date for the full inquest once they are content that everything is ready to proceed.

What do I need to know before the Inquest hearing?

There are considerably more remote Inquest hearings, which means that the evidence is heard remotely with no one in court other than the coroner and the Coroner’s officer.  Although witness evidence can be given by a video link, the Chief Coroner has given guidance to all coroners that, generally, witnesses should be attending the court in person, and that they need a good reason why they should not attend.  The Chief Coroner’s guidance No 38 (absorbed into Guide 34) deals with this issue and is a helpful guide here.  There are many other guides available by searching on the Chief Coroners Guides Service here.

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In circumstances, such as an accident at work or death in custody, a jury has to be called. Although in most cases it is at the discretion of the Coroner, there are some instances where an inquest may involve a jury if there is public interest where there are wider ramifications.

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When attending before the Coroner they should be referred to as Sir or Madam.  and we recommend that all clients wear smart casual clothing, it is not necessary for you to wear a suit or formal attire.  Legal representatives will normally wear a suit, and would not be required to wear any formal gown or wig  as we do in a civil court.

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What happens at the Inquest?

Firstly, the Coroner will explain what they have to do during the Inquest. They have to establish the answers to  four questions;

1. who died;

2. where did they die;

3. when did they die;  and

4. how did they come by their death?

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The first three questions are established from information gathered to draw the death certificate, and are recorded for purposes of the Inquest.  The largest part of the focus at the Inquest will be on question 4 - how did they die?

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The Inquest is not a means for the Coroner to assign blame, and nor can the Coroner reach any conclusion about civil or criminal liability. The Coroner's role is to carry out a fact-finding exercise at the same time conducting a thorough investigate into all actions or inactions which may have played a part in the situation.

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Evidence will be heard from witnesses with first hand experience of what occurred, it could be around perhaps care received from health services, to establish if there was a lack of care and if that contributed or was related to the death.  The legal test that the Coroner will apply as to whether there was a lack of care is "on the balance of probabilities" that lack of care was related to the death.  To be able to conclude that the lack of care was related to the death the Coroner has to explore all of the evidence during the Inquest hearing to make their conclusion.

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An Inquest that is likely to last one day or more would usually commence at around 9.30 - 10.00 a.m. and would conclude at around 16:00 hours (4.00 p.m.).  There would be breaks for lunch and throughout the day.  

Witnesses giving oral evidence will usually be questioned by the Coroner first, then by you or your legal representative, and then by lawyers representing other interested parties, such as a hospital or employer.

Once all the evidence has been heard, the Coroner will ask if anyone wants to make any submissions on possible conclusions or verdicts.  What is meant by submissions is that there is a summary of legal possibilities as to what conclusion the Coroner could draw.   If no submissions are made, the Coroner will still reach their conclusion. 

A Coroner can reach a one-word/short form conclusion (such as accident or misadventure or suicide) or can decide to reach a narrative conclusion.  The Coroner is not allowed to use words such as fault or negligence, and therefore the narrative conclusion could include one or two descriptive sentences as to how somebody died.

Even though the medical cause of death has been established by the post mortem, this can be changed by the Coroner after the evidence has been heard at the Inquest hearing.  You will have already been provided with the Interim Death Certificate some time before the Inquest hearing, once the Coroner concludes their verdict at the Inquest hearing you will be able to apply for a final death certificate which can be obtained from the relevant probate registry.

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Not in all cases, however can arise in some, the Coroner has a duty to consider whether a report should be made to the 'relevant authority' if there is a concern, throughout the inquest process, that future deaths might occur in similar circumstances.

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It is possible to Appeal against any decision made by the Coroner through one of two routes, by way of 'judicial review' for which permission of the High Court is usually required, or where you need the permission of the Attorney General.  There is a very short timeframe to bring judicial review proceedings which is within three months of the date of the inquest.

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If we can be of assistance at all in guiding you through the process of Coroners Courts and Inquests, we can be contacted at any time, initially through our portal or email for us to action immediately.