Inquests have become wide-ranging and complex investigations into an individual’s death. They also provide opportunities to quash criticism and exonerate those unfairly criticised.

Organisations should engage with the process and be responsive to requests by coroners for information so that detailed investigations can be performed.

Following Kennedys' recent workshop on inquests, we summarise below the key points that were explored.


  • Witnesses should become involved at an early stage.
  • As inquests are becoming increasingly wide in scope, the number of witnesses called has increased. A large number of witnesses attending an inquest can be a drain on an organisation’s resources. Early views will need to be taken as to whether additional witnesses will help or hinder the process.
  • Witness statements provided to the coroner in advance should be short, first hand accounts, factual and should not detail opinion. A witness is not being called as an expert. Where appropriate, early submissions should be made for witness evidence to be provided in writing rather than in person (Rule 37, Coroners Rules 1984). This limits the burden on an organisation’s resources and will provide advance notice to all as to what the evidence of that witness will be.
  • An organisation may however want a particular witness called to give evidence in person so as to set out and explain their involvement and potentially quash criticism.


  • If the police are investigating manslaughter and/or gross negligence then an inquest may be opened and adjourned until this investigation is concluded.
  • The HSE may await the outcome of an inquest if investigating health and safety offences, as opposed to gross negligence, before proceeding with its investigation.
  • Witnesses should be forewarned of the potential presence of the individual’s family and media at the inquest. They should be reminded that the aim of an inquest is not to attribute blame. However, witnesses may find the process adversarial.
  • A witness should be aware that he does not have to answer questions which may incriminate and should be warned that evidence provided at an inquest may be used in subsequent proceedings.
  • In the event of an "unlawful killing" verdict it is likely that the case will be referred to the police/CPS so that manslaughter proceedings can be considered against the organisation/individual.


  • Verdicts may be short form or narrative. An example of short form would be "natural causes". A narrative verdict is a factual statement which sets out the circumstances of the death.
  • "Neglect" may potentially be part of a narrative verdict if there was a gross failure and a causal connection between the neglect and the individual’s death.
  • Rule 43 reports are becoming increasingly common. These are reports in which a coroner draws attention to a particular concern established during an inquest with the aim of preventing a future occurrence.
  • With the aim of avoiding a Rule 43 report, an organisation should pre-empt areas of concern and provide evidence of the steps that have been taken or are due to be taken to avoid future adverse events. In addition, key witnesses should be available to explain why an event could not have been avoided, if that was the case, and, crucially, how new changes in place will prevent a similar incident occurring again.


  • A strategy should be agreed in advance so that any responses are provided swiftly.
  • The organisation’s board should meet at an early stage and agree a carefully worded press statement, with staff briefing notes and safety alerts. These should be considerate to the feelings of the family.
  • It may be of benefit to make early contact with the family to express sympathy.
  • The organisation should also communicate with its employees to provide support and avoid inaccurate information being given to the media.
  • All communications should remain consistent. A spokesperson should be identified as a central individual who is backed up by the team. This will ensure the organisation speaks with "one voice".