Most deaths occur naturally or as the result of an illness which can easily be identified by a Doctor as the cause of death. Where the reason for death is not obvious or it happens in a violent or unnatural way, an Inquest needs to be held to investigate the circumstances of the death. An Inquest is the legal process of finding answers to the question of who died, where and how?

When is an Inquest required?

In cases where the cause of death is not clear, or may be suspicious, a referral should be made to the Coroners Office. The Coroner then decides whether an Inquest is needed to find out how and why the person died. The role of the Coroner is to establish the circumstances of the death and the facts relating to it. In some cases the Coroner will sit with a Jury who will decide why the person died.

The Coroner will usually open an Inquest where there are reasons to believe that the death was violent or unnatural, or where the cause of death is not known. The Coroner ‘must’ open an investigation if the deceased died while in prison, police detention or in a mental health institution.

Who takes part in an Inquest?

An Inquest is held by a Coronor who is an independent judge, usually from a legal or medical background. They can hear evidence from witnesses who can help establish the facts, from experts who may prepare reports to assist the Inquest in reaching its conclusion, and sometimes lawyers for the parties involved. The family of the deceased can attend hearings as well as the media.

What happens in an Inquest?

During an Inquest, the hearings are held in public, except where certain sensitive circumstances mean that part of the hearing must take place in private. When an Inquest is required, the Coroner must ‘open’ it as soon as possible and then, if necessary, adjourn it to gather evidence. Where the identity of the deceased is already known, subject to the need for a Post-Mortem, the body can be released to the family for burial or cremation.

The Post-Mortem may reveal the cause of death meaning there is no need for a full Inquest. Where for example, it is found that the death resulted from natural causes that will conclude the process. If further investigation is required the Inquest will be opened and adjourned.

The Inquest should take place within six months or as soon as reasonably possible after the death has been reported to the Coroner. In very complex cases this period can be extended. The hearings themselves can range from a few hours in duration to many months.

During the Inquest, the Coroner will hear evidence from witnesses and consider other evidence such as the Post-Mortem or experts reports. It is up to the Coroner to decide what evidence can be heard. As the objective of the Inquest is only to discover the facts leading to death, it cannot find anyone criminally responsible. However, where a crime is suspected, the Coroner can refer the case to the police or Crown Prosecution Service.

The Coroner is also able to call witnesses dealing with any issues that could lead to deaths in similar circumstances. This is part of the Coroners role to prevent future deaths. The facts of the Inquest may be passed on to organisations to improve systems and procedures which might have contributed to the death. A common example of this is failings in hospital procedures and the Inquest can make recommendations so that similar deaths are avoided.

Having considered all of the evidence, the Coroner has to reach a conclusion on the cause of death. The most common conclusions available are:

  • an accidental death or by misadventure
  • a narrative conclusion detailing the circumstances but without naming any individual(s) as responsible
  • an alcohol or drug related death
  • industrial disease
  • an unlawful killing i.e. murder or manslaughter
  • death by natural causes
  • an open conclusion, meaning there is not enough evidence to decide
  • a road traffic collision
  • suicide

The decision is reached on the ‘balance of probabilities’, except for unlawful killing which must be decided on the basis of the criminal standard of proof of ‘beyond reasonable doubt’. Once the cause of death is established, the Coroner will write a report and the death can be registered.

Conclusion

The Inquest process is vital in ensuring that the circumstances of unnatural deaths are properly investigated. It ensures that justice is done where the death is the result of the actions of others and can help bring about change to avoid similar deaths.  It provides answers to families to questions about why their loved one died.

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