An inquest is an investigation into a death that is not immediately explainable. It is conducted when someone has died suddenly, violently or unnaturally, died while in state custody, or when the cause of death remains unclear after a post-mortem examination.
In this guide we indicate the purpose and different types of inquests, highlighting when a jury is required and the conclusions that the coroner, or jury when in place, can reach in an inquest. We also set out the process of inquests in detail and advise on the steps an organisation should take if involved in a fatality.
The aim of an inquest is to answer four statutory questions - who the deceased was, and when, where and how they died. They are inquisitorial proceedings to establish facts, and whilst it is inevitable that potential failings of organisations or individuals may be identified during the process, inquests don’t seek to allocate any blame or responsibility for a death, or to establish any criminal or civil liability.
An inquest is led by a coroner, who functions similarly to a judge. It’s their responsibility to conduct a ‘full, frank, and fearless’ investigation into an unexplained death, so that the four statutory questions can be determined. It’s common for coroners to dedicate the most time to exploring the questions of how the deceased came by their death.
The coroner has significant discretion in deciding what matters will be examined, which documents will be considered, who will be required to participate in the inquest, which witnesses will be called, and the timing and duration of the inquest. However participants, usually through their legal representatives, can make representations to the coroner on how they believe the inquest should proceed.
There are two types of inquests, named after landmark legal cases: ‘Jamieson’ inquests and ‘Middleton’ inquests.
A Jamieson inquest is narrow in scope and doesn’t explore broader systemic issues or preventability when focussing on how the deceased died. The question of how the deceased died simply means ‘by what means?’.
A Middleton inquest, also known as an article 2 inquest, arises in circumstances where a duty was placed on the state to protect the deceased's life under article 2 of the European Convention on Human Rights. These inquests occur in cases such as deaths in police custody or where other state agents were involved, such as the local authority. They examine not only by what means a person died, but also in what circumstances. This entails delving deeper into potential systemic issues and looking at whether more could have been done to prevent the death. A jury is often called in these inquests to assist the coroner in determining the facts and reaching a conclusion.
Those who participate in an inquest are known as ‘properly interested persons’ or IPs. The family of the deceased will always be granted IP status at an inquest as they are considered to be at the heart of the process. The coroner ultimately decides who else is given IP status, depending on the circumstances of the death.
It’s common for the relevant police force, NHS trust, or ambulance service to be IPs where they have been involved, as well as any other organisation or individual that the coroner deems to have a ‘sufficient interest’ in the outcome of the investigation. For example, the deceased’s employer in circumstances where there is a workplace fatality, will usually be an IP. Individuals can also be IPs as can regulators.
Where an organisation is granted IP status, they might find that individual employees or persons within their organisation are called upon as witnesses to provide evidence about what they saw, heard, or know relating to the events under investigation. IPs will usually also provide disclosure of information to assist the coroner in establishing the facts.
IPs have certain rights in an inquest. For example, the right to receive disclosure, attend hearings, question witnesses, and make submissions to the coroner. IPs are also entitled to legal representation to advocate. In contrast, witnesses in an inquest don’t have these automatic rights.
In most inquests, the coroner alone reviews the evidence presented and reaches a conclusion about the individual’s death. However, in certain cases, the coroner may call a jury to make this determination, providing them with guidance throughout the process.
There are certain circumstances where it’s mandatory for a jury to be called. These include:
In addition to the mandatory cases, coroners have the discretion to call a jury if they believe there are sufficient reasons to do so. Factors influencing this decision can include:
Whilst having a jury can enhance the perceived fairness and democratic nature of an inquest, there are situations where it may be deemed less appropriate. For example, if the case is highly technical or involves complex documentation, a coroner with relevant experience may be better suited to evaluate the evidence.
Parties to inquests need to be prepared, where there is a jury, for questions to be raised by the jury with witnesses and for the inquest overall to proceed at a slower pace. This is due to the need for the jury to have breaks, to have the evidence summarised to them and to receive directions on the law before the retire to consider their conclusions.
There are a range of ‘short-form’ conclusions that the coroner, or jury when in place, can reach in an inquest. These include:
Alternatively, a narrative conclusion can be reached. This enables a brief factual description of the circumstances by which a death came about, if it’s not possible to satisfactorily record the circumstances of a death using a short-form conclusions. Sometimes a short-form conclusion may be combined with a short narrative conclusion to set out wider circumstances.
Below is a flow chart providing an overview of the inquest process.
It’s important to note that inquests may not always exist in isolation. There are often occasions where the police, the HSE, CQC or other regulators have carried out, or propose to carry out, their own investigation into the death, which may lead to criminal enforcement action, including prosecuting individuals and organisations. These bodies may elect to defer their enforcement decision until after the inquest so that they are in a position to consider the evidence heard at the inquest when deciding on their enforcement response. Therefore, while the inquest can sometime appear narrow in focus and fact finding only, it’s important to have regard to these wider considerations during the inquest process.
Civil proceedings may also be brought by family members following the conclusion of an inquest if, for example, potential breaches of duty of care are discovered during the inquest process.
In inquests, the coroner has the power to issue a prevention of future deaths (PFD) report, setting out recommendations to organisations to ensure that lessons are learned and that appropriate changes are made to policies and procedures so that future deaths don’t occur. The recipients are required to respond to the report within 56 days to evidence how such recommendations have been implemented.
All PFD reports and responses are publicly available on the UK judiciary website, potentially exposing organisational failings and risking reputational damage. It’s therefore key for organisations to illustrate from the outset of a death that lessons have been learned and that effective changes have been made so that no similar incidents can occur. This can be looked on favourably and may lead to the coroner not issuing a PFD report.
Should your organisation find itself involved in a fatality, you will need to consider the potential legal processes which may follow – including the inquest, and the possibility of a police and/or regulatory investigation and civil claims.
From the outset you will need to think about document preparation and preservation, and whether you should be conducting an internal investigation and witness interviews into what has occurred. Inquest proceedings can take many years to conclude and knowledge of what occurred will fade and key people may move on from the organisations involved during this time. You need to take this into account early to avoid a last-minute scramble to locate key witnesses and relevant information.
You should also think about responsibilities – who is going to manage your interactions with regulators, the coroner, or the police? Engaging legal support early can ensure a consistent approach to engagement with these third parties and the legal processes.
Inquests can be high-profile and demanding events that can have a significant impact on organisations or individuals. It’s important to recognise the management time and resource that will be required if you find yourself involved in the process.
There are no short cuts and having an experienced legal team on hand means it can shoulder the burden from the initial groundwork through until the conclusion of legal proceedings. Early advice can also help you ensure you take the correct steps at the outset to protect your business and reputation.
At Ashfords we have a dedicated team of regulatory lawyers with a wealth of experience in supporting IPs in inquests across all sectors. This includes corporate organisations, charities, individuals and family members of the deceased. If you’re seeking support, we will be very happy to guide you through the process. For further information and advice, please contact our regulatory team.
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