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Published 01st April 2019 by | Medical Negligence

What is the purpose of a Coroner’s Inquest?

All deaths in the UK have to be registered, but in some cases a local Coroner will need to investigate. When someone is thought to have died in violent or “unnatural” circumstances, or the cause of death is unknown, or the person died while in custody, it should be reported to the local Coroner. The Coroner will then make a decision as to whether the death should be investigated and if an inquest should be held.

An inquest is a public court hearing. However, unlike most court cases in the UK, it is not an adversarial process where one side is arguing against the other, with a judge deciding between them. An inquest is an inquiry conducted by the Coroner with the main objective of establishing the facts of what happened. The Coroner decides which issues need to be looked at, and what evidence should be heard.

The purpose of the Coroner’s inquiry is broadly to answer the following four questions in relation to the person who has died:

Who they were;
When they died;
Where they died;
And how they died.

With most inquests, the answers to the first three of these questions will already be known, and so the inquest would usually focus on how the person died. The Coroner would make decisions about what issues or facts they need to investigate in order to answer those questions.

The purpose of an inquest is not to blame anyone for the death. The Coroner’s Rules make it clear that a Coroner is not usually allowed to reach any conclusion that would hold someone responsible for the death.

However, during the inquest itself the Coroner can consider these issues. If the Coroner considers that the evidence suggests there is a continuing risk to the public then they are under a duty to investigate that and if necessary, prepare a report asking an organisation or individual to consider those issues and provide a response to the Coroner.

The Inquest Process

As part of the process, the Coroner should identify any ‘Interested Person’. This may be an individual person such as a family member, though in many cases the Coroner is willing to deal with the family as a group. Likewise, it may include an individual person involved in the deceased’s care and treatment prior to their death such as their GP, or it may include an organisation, such as an NHS hospital.

The inquest is a public hearing and so anyone can attend and listen to the evidence. Interested Persons may take part in the inquest and make suggestions or representations to the Coroner concerning the inquest. In complex cases, there may be a hearing before the actual inquest, to allow the Coroner to make sure that everything necessary for the inquest hearing is ready. This is called a ‘Pre-Inquest Review’, and can make decisions on things like:

  • What issues or events the inquest will consider – often referred to as the ‘scope’ of the inquest.
  • Which witnesses should attend the inquest to give evidence, and whether any further written statements or reports are needed from witnesses.
  • Whether any further documentation needs to be provided to the Coroner, for example medical records.
  • When the inquest should take place.

At the Pre-Inquest Review hearing, the family and any other Interested Party can comment on the above issues and makes suggestions to the Coroner, but the Coroner makes the decision.

Any Interested Party is entitled to copies of any documents held by the Coroner. Many Coroners will arrange for statements and other documentation to be automatically sent to the family, or a lawyer on their behalf, while in some areas, copies of documents will only be provided upon request.

The preparation for the inquest can sometimes take several months, and it is not unusual for an inquest to take place 6-12 months after someone has died. However, if a Coroner has not held an inquest within 12 months of being notified of the death, the Coroner must then notify the Chief Coroner about the delay and then confirm when the inquest has concluded. While this rule was introduced to try and avoid lengthy delays, one unfortunate side effect is that it can mean that a Coroner holds an inquest either very close to or even on the first anniversary of the death.

The Inquest Hearing

Most of the inquest hearing itself is focused on hearing evidence from witnesses. Witnessed are called and give evidence on Oath as they would in any other Court hearing.

Witnesses would usually have prepared something in writing first, and this would usually have been seen by the Coroner and all Interested Persons, including the family.

A Coroner’s inquest sometimes appears less formal than other court hearings, and the way in which a Coroner manages a witness’s evidence can vary. The Coroner may ask the witness to read their statement out loud, or they may simply ask them to confirm that the contents of the statement are true. Sometimes the Coroner might go through the statement with the witness and ask the witness questions if more information is needed.

The Interested Persons can then ask questions themselves, or a lawyer can ask on their behalf. If these questions, or a witness’s answers, raise additional issues, the Coroner could ask further questions.

The Coroner will make a summary of evidence once this has been heard.  The Coroner may also make specific findings of fact, especially if there is conflicting evidence from witnesses. The Coroner will also make the formal decision of the medical cause of death and this is included on the death certificate.

Finally, the Coroner would announce their Conclusion – previously known as a verdict. The Coroner’s Conclusion will usually be a ‘Short Form’ conclusion, such as natural causes, accidental death, misadventure, suicide, etc…

In some cases, the Coroner may instead give a Narrative Conclusion. This is a short summary, often no more than 1 or 2 sentences, explaining the circumstances of the death. It should be in neutral language which does not place responsibility on anyone or any organisation, though can still refer to relevant facts.

Whilst the Coroner’s Findings and Conclusion are clearly important, many families find it as useful to hear the evidence themselves, and to reach their own conclusions about what they have heard.

Funding for Legal Representation at Inquests

The inquest can be a complicated and emotional process particularly for the family. Although the inquiry is conducted by the Coroner, many families find it helpful to have a lawyer to support them through the process and to have representation. Many organisations, such as hospitals, will also often have a lawyer representing them, and this can make it more difficult for some families to ask questions, and feel like their voice is being heard.

If a family chooses to have a lawyer, this is not funded by a Coroner. In some cases, lawyers attend an inquest and represent the family as part of the investigation of a Claim. While the Coroner is not usually allowed to hold anyone responsible for a death, many of the facts that are dealt with at an inquest would be relevant to a later claim. If so, it is possible for a Claim to cover some, or all of the legal costs of representation at an inquest.

Families can apply for Legal Aid, but this is only granted for inquests in exceptional circumstances, for example, where someone has died whilst they were in custody, detained for treatment under the Mental Health Act, or in prison. Legal Aid may also be available in cases where there is a wider public concern, for example, where there are concerns with the overall care system. To obtain Legal Aid, a specific application must be made to the Legal Aid Agency and a solicitor can help you with this.

Since many state organisations like the NHS, Police, Ministry of Defence would often have legal representation at an inquest, many people feel that it would be fair for Legal Aid to be available for families in those inquests.

The Ministry of Justice has recently held a review of Legal Aid for inquests, and published its report last month.

One of the questions that the Ministry of Justice considered was whether families should be entitled to legal aid, if public organisations such as an NHS hospital, the police or the prison service were represented by lawyers at the same inquest.

The Ministry of Justice concluded that it would be too expensive to provide legal aid for families at inquests, even if Legal Aid was restricted to those inquests where public bodies were also involved, and had lawyers representing them.

In the same report, the Ministry of Justice considered whether anything could be done to reduce the number of lawyers that state organisations have representing them at inquests. This would help ensure that the inquest remained an inquiry rather than being adversarial. The Ministry of Justice concluded that there is very little that can be done to reduce, or prevent public bodies, such as NHS Trusts, using lawyers.

While it seems that changes to Legal Aid are unlikely, our solicitors may be able to help, even if legal aid is not available.

Our nationally recognised Medical Negligence Team are experts in the field and are on hand to help you at every step of the way.
Contact our team on 01525 378177 or contact us here.

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