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Coroner’s Inquests – What Should You Expect?

  1. What is a coroner’s inquest?
  2. What is the purpose of an inquest?
  3. How does the inquest process work?
  4. Post-mortem
  5. Why is it carried out?
  6. Tips to help you through an inquest

Most deaths occur perfectly naturally and in circumstances where a doctor can quickly establish the cause. Where the reason is not immediately apparent or a persons death seems to have happened in a violent or unnatural way; an inquest is the process of getting answers to the important questions of who died, where and how?

What is a coroner’s inquest?

Ordinarily, a persons death is not referred to a Coroner, and the deceased’s doctor will issue a medical certificate recording the cause of the death. In many cases, the deceased will have been treated for a medical issue just before death. Where the cause cannot be found, a referral should be made to the Coroners Office. The Coroner decides whether an inquest is needed to find out why the person died.

A coroners inquest is a legal inquiry looking into the reasons for a persons death. The role of the Coroner, sometimes along with a Jury, is to investigate the circumstances which caused the person to die and to find out all of the facts relating to the death.

The Coroner should open an inquest where there are grounds to suspect that the deceased died a violent or unnatural death, or where the cause of death is not known. The Coroner ‘must’ open an investigation if the deceased died while in state detention, such as in a prison, police cell or mental health institution.

What is the purpose of an inquest?

The main purpose of an inquest is to determine the important facts relating to the death. It is a legal process to establish the identity of the dead person, how they died, and when and where the death occurred. The inquest can be conducted by a Coroner alone or with a Jury where the death happened in state detention.

Who is involved in an inquest?

Coroners are independent judicial officers and are appointed by the local authority. The Coroner is normally a doctor or a lawyer and is responsible by law for investigating the cause of deaths. There are around 98 Coroners in England and Wales, covering over one hundred coroner areas.1

Other persons involved in the process are witnesses to the facts of the death, experts who may prepare reports to assist the inquest in reaching its conclusion, and sometimes legal representatives of the parties involved. The family of the deceased can attend as can the press as the hearings are held in public, except where certain sensitive circumstances mean that part of the hearing must take place in private.

How does the inquest process work?

When an inquest is required, the Coroner must ‘open’ it as soon as possible and then if necessary, adjourn for the period of time needed to gather evidence. Where the identity of the deceased is known, subject to the need for a post-mortem, the body can be released to the family for burial or cremation.

In some cases a pre-inquest hearing will be needed to set out the scope of the inquest, decide what information is needed and set a timetable for the hearings.

The post-mortem may reveal the cause of death, meaning there is not a need for an inquest. Where, for example, the death happened from natural causes that will conclude the process. If further investigation is required, the inquest will be opened and then adjourned.

The inquest hearing should take place within six months or as soon as reasonably possible after the death has been referred to the Coroner. Sometimes it may take longer than six months to hold the inquest in complex cases. The hearings themselves are often short but can take weeks or months, the Hillsborough football stadium tragedy being one such case.

During the inquest, the Coroner will hear evidence from witnesses and consider other material such as the post-mortem or experts reports. It is up to the Coroner to decide what evidence can be heard. As the purpose of the inquest is limited to discovering the facts of the death the Coroner (or Jury), cannot find anyone criminally responsible for the death. However, if it is suspected that the person died as a result of a crime, the Coroner can pass a file to the police or Crown Prosecution Service.

Any ‘properly interested parties’ can request copies of the statements, reports or medical records to be used in the inquest and can be invited to make representations to the inquest. The inquest takes place in a courtroom, and although it is a process open to the public, reporting restrictions can limit what the press can report. The Coroner and any legal representatives can ask questions of witnesses to try and find out what led to the death. They cannot cross-examine witnesses as the hearing is an investigation and not a Trial. The Coroner does have the power to compel witnesses to attend.

The Coroner is also able to call witnesses dealing with any concerns that other deaths may happen in similar circumstances. This is part of the Coroners role to prevent future deaths. The facts of the inquest may be passed on to relevant organisations to improve systems and procedures which might have contributed to the death.

Once all of the evidence is heard, the Coroner must reach a conclusion on the cause of death. Where a Jury is needed, the Coroner will hear legal submissions (in their absence) on which conclusions should properly be left for the Jury to consider.

The most common conclusions on the cause of death are:

  • accidental death or misadventure
  • narrative detailing the circumstances but not attributing responsibility to any individual
  • alcohol or drug-related death
  • industrial disease
  • unlawful killing, i.e. murder
  • natural causes
  • open, meaning there is not enough evidence to support any other conclusion
  • road traffic collision
  • suicide

The decisions are reached on the balance of probabilities, except for unlawful killing, which must be decided on the basis of beyond reasonable doubt. Once the cause of death is established, the Coroner will produce a report, and the death can properly be registered.


A post-mortem is a medical examination of the deceased’s body, carried out to establish the cause of death. Usually, this involves an internal examination of the body tissue and organs but can also involve toxicology tests to examine if substances are present in the body. Samples can be taken for further tests. Parts of the body may be retained if further tests are required. This may happen where the cause of death is complex or disputed, or a second post-mortem is needed.

Why is it carried out?

The Coroner may conclude that a post-mortem is necessary to find out the exact cause of death, particularly where a doctor cannot identify the reason to record on the death certificate. A post-mortem is conducted by a pathologist. Body parts, organ tissue and fluids are thoroughly examined to try and establish what caused the person to die.

Where a criminal act is suspected of having caused the death, the post-mortem is carried out by a forensic pathologist skilled in such investigations. There is sometimes a request for a second post mortem from legal representatives of any suspect identified. This can cause delay to the body being released and in turn, lead to additional upset to the family of the deceased. The Chief Coroner is able to issue guidance on the appropriate use of post mortems.

Tips to help you through an inquest

Naturally, an inquest is a difficult time for anyone connected to the person who has died. Emotions can be raw, and the hearings may come soon after the trauma of the death itself. There are some useful steps that can be taken to make the process as bearable as possible:

  • make use of the Coroners office that supports the work of the Coroner in each area. They can provide helpful information and guide you through what might seem a complex and daunting process.
  • the charitable organisation, ‘The Coroners Court Support Service’ provides help and support to those going through the inquest process (
  • be well prepared and ensure you are given access in good time to the statements and reports that will form the evidence in the inquest.
  • think about the questions that you might want to ask of the witnesses and perhaps appoint a family member to act as spokesperson.
  • if you are able to have a legal representative involved, this can help alleviate some of the pressures and stress of the inquest.
  • as the hearings are in public there is nothing to prevent you from taking along a trusted friend to provide moral support.
  • don’t do anything or make any decisions in haste. When emotions are very raw people can do and say things that later they regret. Take your time to carefully consider each decision.
  • remember that the purpose of the inquest is to find out why the person died. This may mean that upsetting information is heard, which can be traumatic, but the overall aim is to provide answers, helping people to understand why the death occurred.


The Coroners inquest plays a vital role in ensuring that the circumstances of unnatural deaths are fully investigated. It maintains the legal rights of the deceased’s family and other properly interested persons, referring the matter on to the prosecuting authorities where a criminal act is suspected and can prevent similar deaths occurring in future.  It can aid the grieving process as the family have the chance to take part and to ask questions and discover the facts about how their loved one died.


1Coroners and Justice Act 2009 [Coroner Areas and Assistant Coroners] Transitional Order 2013).

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