A number of recent fatal incidents in the marine environment have resulted in the involvement of statutory harbour authorities, the RNLI, HM Coastguard and industry bodies amongst others having to be involved in inquests and receiving Prevention of Future Deaths (PFD) reports. These incidents and the public hearings into them shine a light on the management of public safety risks and the actions taken by those with legal duties to ensure safety.
This article explores the function of inquests, the role of interested parties, and the legal and reputational risks they face.
An inquest is a formal inquiry led by a coroner into deaths that are sudden, violent, unnatural, unexplained, or occur in state custody. The purpose is to establish the answer to four questions - who the deceased was, when and where they died, and how the death occurred.
Inquests are inquisitorial in nature - the coroner does not apportion blame or determine any civil or criminal liability but seeks to uncover the facts. In doing so, the coroner will reach a conclusion about the death and this will be recorded in a Record of Inquest.
That said, coroners have discretion to set the scope of inquests widely to include evidence regarding wider management issues, and the procedural steps taken by organisations to identify and adequately manage risks. The evidence is presented publicly during an inquest. The coroner may then identify what they consider to be serious failings and organisational shortcomings, sometimes giving the proceedings an adversarial edge, and which puts organisations reputations at risk. It may also expose them to risks of civil claims and regulatory enforcement action.
For more information about inquests, including the types of inquests, the range of conclusions a coroner can reach and the process of inquests proceedings, take a look at our detailed guide here.
Interested persons (IPs) are individuals or organisations granted formal status to participate in an inquest. The deceased’s family are always an IP, but coroners may designate others - such as employers, public or industry bodies, or regulators - who have a significant interest in the events leading to the death.
In a recent inquest, the coroner designated the RNLI, local council, coastguard, and relevant statutory harbour authority as IPs due to their roles in managing public safety in the area where the death occurred.
Being an IP grants rights to receive evidence disclosure, attend proceedings, question and challenge witnesses, and make legal representations to the coroner. It also provides the right to legal representation - which is often advisable when an organisation’s conduct may be scrutinised.
However, IPs must also meet obligations, including: cooperating fully with the coroner, complying with directions, and disclosing relevant materials. Employees of organisations who are IPs may also be called as witnesses. Individual witnesses, unlike IPs, have no automatic rights to disclosure or legal representation.
Although inquests are fact-finding processes, they can lead to far-reaching consequences:
i. Findings of unlawful killing or neglect
A conclusion of unlawful killing or a different conclusion with a neglect rider, which is where it is found that there was a failure to meet basic needs or provide medical attention which directly contributed to the death, can signal gross or systemic failures. Such outcomes are potentially more likely to be reached in the coroner’s court than the criminal courts as the burden of proof is to the lower civil standard - ‘on the balance of probabilities’. Though these conclusions do not directly name individuals, such findings often draw media and regulatory attention, and may trigger further investigations by the police, the Health and Safety Executive (HSE), or other regulators.
ii. Conduct and cooperation
Inquests are held in open court. A failure to disclose documents, comply with directions, or any obstructive and defensive behaviour may draw public or judicial criticism. This is especially important when multiple legally represented IPs are present, where attempts to shift attention upon another as a legal tactic is common. Some organisations like to be legally represented to assist them in striking the right balance between defending their interests and cooperating with other parties.
iii. Scope of the inquest
Coroners have extensive discretion over the scope of an inquest. It can range from focussing on the immediate events to much broader issues, such as a deeper exploration into internal policies, practices and training. IPs must be prepared for the inquiry to include these wider organisational factors.
iv. Prevention of Future Deaths (PFD) Reports
If the coroner identifies risks that could lead to future deaths, they have a duty to issue a Prevention of Future Deaths (PFD) report. PFD reports outline a coroner’s concerns and recommends that steps should be taken to prevent similar deaths. It's sent to relevant organisations or individuals and published on the judiciary website, making it accessible to the public and media. This transparency can carry serious reputational risks, especially when the report highlights internal failings.
Recipients of PFD reports must respond within 56 days, outlining actions taken or planned, or explaining why none are proposed. While coroners can’t enforce compliance, the chief coroner’s recent move to publish a list of non-responders annually has raised the stakes - potentially attracting media scrutiny, reputational harm, and regulatory attention. You can read our related article here.
v. When you are not an IP
Some organisations may not be designated as IPs but still have employees called as witnesses. These individuals may find themselves at a disadvantage, as without IP status, they have no automatic right to view disclosure from other parties, receive legal representation or challenge others’ testimony. This can lead to situations in which misleading or incomplete information about them or their employer goes unchallenged.
Where there is a risk that the individual may face criticism, it’s often wise for them or their employer to apply for IP status, to ensure appropriate oversight and support.
vi. Broader legal and regulatory risks
Inquests rarely occur in a vacuum. Evidence disclosed or conclusions drawn may be used in subsequent criminal, regulatory, or civil proceedings. Bodies such as the police, HSE, or sector-specific regulators may have an interest in the case and could rely on inquest findings when deciding whether to pursue action. In addition, the family of the deceased may choose to bring a civil claim, either before or after the inquest has concluded. Actions taken - or not taken - during the inquest can influence how future proceedings unfold. Because of this, organisations involved as IPs must carefully consider the wider legal landscape that the inquest may be playing out within.
vii. Jury inquests
Some inquests - such as those involving state custody or where the death resulted from an incident reportable to the HSE - are heard by a jury. These pose added risks due to the challenges involved in laypersons evaluating complex evidence and potentially drawing adverse conclusions.
viii. Risk of self-incrimination
Although inquests are not designed to determine criminal liability, there remains a real risk of self-incrimination, as evidence given under oath can be used in subsequent criminal, regulatory, or civil proceedings. While individuals have the right to decline to answer incriminating questions, this protection must be carefully managed. Without legal advice, those giving evidence may unwittingly expose themselves or their organisation to risk.
Inquests can take months or even years to conclude. Preparation is essential - from the moment an organisation becomes an IP or learns a staff member is due to give evidence. Key steps include:
In the aftermath of a fatality, organisations are also likely as part of their, a regulator’s incident response, to:
Recent inquests stand as a reminder of the significant responsibilities faced by organisations tasked with public safety - particularly those operating in ports, harbours, and other high-risk environments. Further, the issuing of PFD reports to such organisations can present reputational and legal risks.
Such incidents underscore the importance of proactive safety management and the value of inquests as tools for learning and prevention of similar incidents. But inquests and the coroner’s power to issue PFD reports also expose organisations to reputational, regulatory, and legal scrutiny.
When fatalities occur, organisations involved must be properly prepared to be involved in inquest proceedings. Early planning, coordinated responses, and the correct support can assist with contributing meaningfully to the fact-finding purpose of an inquest, while also protecting interests and maintaining public trust.
If you would like further information or support in relation to any inquest or regulatory support in relation to a fatal accident, please contact Ashfords’ business risk and regulation team.
We produce a range of insights and publications to help keep our clients up-to-date with legal and sector developments.
Sign up
