A family member has recently died. Why does there need to be an inquest?

An inquest is the state’s investigation into why a person has died. For an inquest to happen there must be concerns about how the person died. If the person’s death was:

  • violent or unnatural;
  • the cause of death is unknown; or
  • the person was in prison or in a mental health hospital, or otherwise under control of the state;

In these circumstances, there should be an investigation and an inquest.

If you have concerns about a loved one’s death, you can ask the relevant authority, be it a hospital or police, about an inquest and if one will be taking place.

Where there are concerns, an inquest needs to take place to establish how the person died, so that the cause of death can be registered on the death certificate. A final death certificate won’t be released where there is an inquest until the inquest and its investigations have concluded.

An inquest is also necessary to make sure that if mistakes have been made and other people’s safety is at risk, that these issues are dealt with.

Who runs the inquest?

The inquest and investigation are run by the coroner. They are helped by coroner’s officers, who will be the point of contact for any family members and witnesses, and can help with information about the inquest and may help with taking witness statement from you.

What do I need to do for the inquest?

You may be asked to set out your concerns in writing to assist the coroner. Sometimes this can be in a witness statement, sometimes it can be in a letter.

Although the inquest is not purely for the benefit of the family and the family cannot demand outcomes or particular actions in the inquest, you and any family members will play an important role in establishing some of the issues the coroner will need to consider. The coroner’s court also recognises the important opportunity that the inquest provides to friends and family in getting answers as to why their loved one has died.

Who can go to the inquest?

An inquest is an open hearing, and any members of the public are allowed to attend. Press can also attend inquests, and you and any family should be aware of this when attending an inquest. You do not have to talk to anyone from the press, and this is entirely your decision.

Who will be at the inquest?

The coroner will be at the inquest and run the inquest, in much the same way as a judge would do.

There will also be witnesses relevant to the person’s death, who will give evidence during the inquest.

There may be lawyers for witnesses who are attending, for a hospital and if the family has a lawyer, then they will attend too.

Sometimes, the coroner will decide that the issues are of such significant concern, that a jury needs to be at the hearing to decide how the person died. This only usually happens when the person has died in a mental health hospital, in prison or in police custody.

What happens at the inquest?

The coroner will start by explaining the details of how the person died and what issues are to be considered.

It you or any other family member has provided a statement, or set out concerns, the coroner may ask that these are read out in court by you. You, or any family member, will not be questioned by lawyers like a criminal court; the purpose of having concerns set out is to help establish key issues relevant to the inquest, not to question you or any other family members. The coroner may take you through your statement and ask you to talk about any concerns, but this will only be to establish the relevant issues.

The coroner will then call different witnesses relevant to the person’s death who have been asked to attend the inquest. These might be police officers, pathologists, doctors, nurses, or anyone else involved in the events leading up to the person’s death. The coroner will ask questions, and then any lawyers acting either for the family, witnesses, hospital or police may ask some questions.

What is the outcome of an inquest?

An inquest is not like a criminal trial; there are no verdicts or sentences. The purpose of an inquest is not to establish blame or guilt, but to find out the facts of how the person died. This can often be frustrating for families, as fault or negligence is not usually established and there is no punishment.

If there is a jury, the coroner will direct the jury about the evidence they have heard and ask them to come to a conclusion.
If there is no jury, the coroner will consider the issues themselves.

The outcome of an inquest is that findings are made, rather than judgments. A coroner can make many findings of how a person died, such as that the cause of death was:

  • accident;
  • industrial disease;
  • lawful/unlawful killing;
  • natural causes.

A coroner can also deliver a narrative conclusion, where the causes of death are described and set out in more detail where the circumstances are less straight forward. This is common where there are concerns that the person has died due to errors at a hospital or prison, and the details of this need to be set out.

If the coroner has concerns about the nature of the death, they can prepare a ‘Prevention of Future Deaths Report’ which is sent to the hospital, prison or other body with duty of care to the deceased setting out the concerns and what needs to be changed, and set a deadline for a response. This report can also be sent to the family.

Does an inquest mean that there has been negligence?

If your loved one has died in hospital and you are concerned that there has been medical negligence, an inquest will not usually provide some answers about this. The inquest can be a very useful step for a family or friends to try and make sense of what has happened, but it is often only the first step in obtaining answers.