Attending an inquest is almost an inevitable event when you work with elderly or frail people, but is still a daunting experience if you are not familiar with the processes and what to expect. Victoria Davies, Senior Associate and Assistant Coroner has prepared the guide below to assist your team in what to expect on the day.

The purpose of an inquest is to find out how an individual came by their death. The coroner - who leads the inquest - will be looking to answer four questions: who, when where and how.

An inquest is not always required when somebody dies, only if they died a violent or unnatural death, the cause of death is unknown, or they died while in custody or state detention.

It is important to remember that nobody is on trial, and the coroner is not permitted to apportion blame.

What will happen on the day?

The coroner will explain the purpose of the inquest and give the background as to what has happened procedurally to date. Usually, the family members will give evidence first, followed by the rest of the witnesses. When it’s your turn, you will be asked to swear in either by a religious oath or affirming; essentially a promise to tell the truth.

The coroner will lead the questioning and then the family will have an opportunity to ask further questions. If there are any other interested persons, they can ask questions next. If you have one, your legal representative can ask follow-up questions once everyone else has asked.

Once all of the evidence has been heard, interested persons have the opportunity to address the coroner on points of law. This will generally relate to which conclusions are most appropriate and whether the duty of the coroner to issue a Regulation 28 report is engaged.

The coroner will then usually adjourn for a short period of time to consider the evidence. When they return, they will deliver their conclusion, which will signal the end of the inquest.

Key terms

There are a number of key terms used in inquests, being familiar with these will help you to understand what is happening:

  • Interested persons - people who have a proper interest in the inquest. This will include family members, anyone whose actions may have contributed to the death and anyone who the coroner feels has a proper interest. This could include a care home, a carer, or an independent clinician.
  • Rule 23 - the Coroner can admit written evidence under this rule without requiring the author to attend court.
  • Regulation 28 report/preventing future deaths report - the coroner has a duty to write to any person or authority that has the power to take action to prevent future deaths, if they feel that circumstances still exist whereby there is a risk of other deaths occurring in the future.
  • Conclusion - this is the coroner’s verdict. The most common are:
    • Natural causes - the death was caused by the normal progression of a natural illness or disease
    • Accident/misadventure - an unintended act or omission, or an intended act which unintentionally leads to death
    • Suicide - where the deceased intentionally took their own life.
    • Neglect - this is added to a conclusion where the coroner feels that there has been a gross failure to provide basic medical care, which caused or contributed to the death
    • Narrative - this is usually a short paragraph explaining how the deceased came by their death

Top tips

  • Read your statement and familiarise yourself with the records in the few days prior to the inquest. It’s not a memory test and you will be able to refer to notes when giving your evidence, but it helps to know where to find the answer if you don’t remember it.
  • Consider what information the coroner may need to hear in order to understand the circumstances of the death.
  • Check where the court is and how you are going to get there.
  • Wear smart clothing or your uniform; along the same lines as a job interview.
  • Arrive early.
  • Don’t rush- think about your response before answering.
  • Don’t be afraid to ask for the question to be repeated or clarified.
  • Be honest!