The period following the death of a loved one is a traumatic and difficult time but what happens when an Inquest has to take place? Despite the best endeavours of the police, Coroner's Officers and Court staff, this can be a confusing time for family and friends of the person who has died.

What is an Inquest?

An Inquest is an investigative process to determine:

  • Who the deceased was;
  • When and where they died; and
  • How the deceased died and in what circumstances

The Coroner also has a duty to consider whether it is necessary to submit a Prevention of Future Deaths Report, if there is anything that arises during the course of an Inquest that leads the Coroner to suspect that future deaths may occur unless action is taken.

The coroner (or sometimes a Jury) must only seek answers to those questions. It is not a process in which blame is attributed and the Coroner or the Jury must not consider issues of civil or criminal liability and this is often misunderstood. This is why the Coroner’s Inquest is described as “inquisitorial”.

Why is an Inquest held?

An Inquest is held if any of the following circumstances have occurred:

  • The cause of death was violent or unnatural
  • The person was in state detention when they died
  • The cause of death remains uncertain following a post mortem

What happens at an Inquest?

In the lead up to the Inquest, the Coroner’s Officer will liaise with all Interested Parties, which includes family members and, sometimes, friends of the deceased.

There may be a Pre Inquest Review where the Interested Parties are invited to attend a meeting with the Coroner to discuss the main issues that will be the focus of the Inquest and the necessary evidence. That evidence might include Witness Statements from friends and family.

The Inquest itself is usually held at the Coroner’s Court in the jurisdiction (geographical area) in which the death occurred but this is not always the case and the Coroner’s Officer will confirm the details well in advance of the Inquest start date.

The evidence will be heard by the Coroner and/or the Jury at the Inquest, either by statements being read out in Court or by witnesses attending in person and answering questions under oath. The Coroner may decide that some evidence is not required at the Inquest because it does not assist in determining who the deceased was and how, when and where they came by their death. It is the role of the Coroner’s Officer to explain who will be required to attend in person to give evidence and whose statements will be read out. Interested Parties are invited to ask questions about the evidence but it must be remembered that the purpose of the Inquest is narrow, as outlined above. Witnesses can be stopped from answering any questions that stray outside this narrow scope i.e. questions that seek to attribute blame that could lead to a criminal or civil liability.

The Inquest can last for part of a day, for several days or occasionally several weeks and it is also worth remembering that the press may attend.

Once all the evidence has been heard and any questions from the Interested Parties answered, the Coroner or Jury will need to time to consider all the evidence and will make a determination about who has died, where, when and how they died. Findings will also be made to assist with the recording of the cause of death. This can sometimes happen on the day but, particularly in cases involving complex issues and multiple witnesses, the Coroner or Jury may make a determination on another day.

What findings can a Coroner or Jury make?

A Coroner or Jury can determine that an individual died from:

  • Natural causes
  • Accident or misadventure
  • As a result of alcohol or drugs
  • Industrial disease
  • Lawful killing
  • Unlawful killing
  • Road traffic accident
  • Stillbirth
  • Suicide
  • Neglect

A Coroner or Jury may also reach an Open Conclusion, which is where they have been unable to determine the cause of death following the consideration of all the evidence and none of the other verdicts are applicable. A Narrative Conclusion can also be found, in which the circumstances of the death are set out in detail, and can sometimes include any critiscms that the Coroner wishes to make.

Importance of the Coroner’s Officer

The Coroner’s Officer is key to providing Interested Parties with information about how the Inquest will be conducted and what to expect on the day. They are extremely knowledgeable and provide support during the Inquest process, which is crucial when Interested Parties are grieving and struggling to come to terms with what has happened.

In our experience, Coroner’s and Coroner’s Officers are respectful and acutely aware of the difficult circumstances surrounding the death of loved ones; the process is built around respect for the deceased person and finding answers to important questions about how the death occurred.