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By Victoria Hydon, Partner, Moore Blatch

What is an Inquest?

Where there has been a sudden or unexpected death there will be an inquest into the circumstances of that death.  The inquest will be limited to the following four questions:

  • Who died?
  • When did they die?
  • Where did they die?
  • By what means and in what circumstances did they die?

An inquest does not determine either civil or criminal liability. It is about what happened not who was responsible for what happened.

Where and when will the Inquest be held?

The inquest will be held in the county where the deceased died.

Shortly after the death the inquest will be opened after confirming the identity of the deceased and then adjourned to a later date to enable the Coroner to make investigations.  The Coroner is an independent judicial office holder. The Coroner will release the body for burial/cremation within 28 days of death or give reasons to the next-of-kin why the body cannot be released within this timescale. 

An inquest must be completed within 6 months of the date on which the Coroner is made aware of the death or as soon as reasonably practicable after the date.  If inquests are not concluded within a year of death the Coroner must notify the Chief Coroner giving reasons as to why the inquest has not yet concluded. 

Representation at Inquests

An inquest is a public hearing, anyone, including press can attend. The family of the deceased can be represented by:

  • Solicitor
  • Barrister
  • Legal Executive (with rights of audience)
  • Registered European Lawyer
  • A properly interested person

A “properly interested person” is normally a parent, spouse, child, civil partner or partner or the personal representative of the deceased. However, it can be anyone else who the coroner may decide also has a proper interest in the inquest.

It is not always necessary for the bereaved relatives to attend the inquest. Whilst is not compulsory to have legal representation, in most cases it is prudent to instruct a solicitor and/or barrister.

How to choose a solicitor

It is important to find a solicitor with expertise of inquests or of the circumstances of the death. When choosing a solicitor the following may be helpful:

  • Solicitors with experience of clinical negligence claims
  • Solicitors who have both legal and medical qualification
  • Solicitors whose firm have a legal aid franchise to conduct any subsequent civil proceedings
  • Solicitors who have particular experience in, for example, catastrophic brain injury cases

If you need help with finding a solicitor, The Law Society provides information to help you find the legal support you need.

Will funding for Legal Representation at an Inquest be available?

Legal Aid is not generally available for representation at inquests.

Legal Aid will only be available in exceptional circumstances, namely

a)           The inquest is likely to invoke Article 2 of the Human Rights Act (right to life).

b)           Where the Director of the Legal Services Commission has made a “wider public interest determination” in relation to the individual and the inquest.   This is a determination that in the particular circumstances of the case the provision of advocacy for the purpose of the inquest is likely to produce significant benefits for a class of person other than the applicant and members of the applicant’s family.

In order for an exceptional inquest case to be funded, the client must satisfy the Legal Aid financial eligibility limits.  In practice, if an applicant is working on a full time basis it is unlikely that legal aid will be granted.  

Sometimes it is possible to fund your legal representation at inquests funded by

  • Conditional Fee Agreement (no win, no fee).  

A Conditional Fee Agreement is a contract between the personal representatives of the Estate of the deceased and the solicitor.  The Conditional Fee Agreement will cover the costs associated with the inquest and any subsequent civil claim.  If the civil claim is unsuccessful the solicitor will not be entitled to his or her costs in relation to the inquest.   If, however, the claim is successful the Defendant (the person/trust/organisation who caused the death) will pay the solicitors reasonable costs in addition to any compensation. 

  • Before the event legal expense insurance

Frequently household or motor insurance policies also provide legal expense insurance for persons intending to pursue a civil action such as a personal injury or clinical negligence claim.

If you have any queries related to the funding you need to ask your solicitor to explain very carefully the costs to you.

Preparation for Inquests

The bereaved should appreciate that inquests will not always provide a thorough examination of the circumstances leading to the death, or that the findings will satisfy their need for public recognition.    However, an inquest provides the best opportunity to unearth key information and facts that may be of help in any subsequent civil proceedings, for example arising out of medical negligence.

Under the direction of the Coroner, the Coroner’s Officer will obtain statements from those persons who gave care/treatment to the deceased, and anyone else including family members who may have information that might assist the Court. The Coroner is now obliged to disclose the statements/reports to an interested person and/or his legal representative unless the statement/reports are irrelevant to the investigation or a request for a statement/report is unreasonable. 

Post Mortem reports must be disclosed by the Coroner prior to the inquest to the bereaved family and/or their legal representatives.  A Post Mortem examination is a medical examination of a body carried out by a pathologist to establish the cause of the death. Relatives can now insist that a Coroner instructs an appropriate pathologist – for example where a child has died relatives can request a paediatric pathologist. 

Family’s expert evidence – if the bereaved family obtain their own independent evidence it should be disclosed to the Coroner prior to the inquest if it is to be relied on.  The family will bear the cost of their independent expert report.

Any protocols/guidelines as to treatment should be sent to the Coroner prior to the inquest. Medical records and notes should be provided to the Coroner in a paginated chronological form if obtained by the family. Coroners may now admit the findings of any previous inquiry in evidence. 

Pre-inquest review

These reviews precede the inquest itself and are used to clarify the issues that will be addressed at the inquest. Pre-inquest reviews are now recorded and will deal with such matters as:-

  • The extent and timing of disclosure of evidence
  • Which persons will be called to give oral evidence.
  • The location and timing of the inquest.
  • The need for a jury.
  • The need to admit any other evidence.
  • The need for expert evidence

A witness can now be compelled to give evidence at an inquest.  However, written evidence will be admitted if it is not possible for a person to attend within a reasonable time or where there is good reason and sufficient reason why that person cannot attend.  Witness evidence can be via a video link or behind a screen. 

The Inquest

Unlike civil or criminal proceedings an inquest is not an adversarial process where one party has to prove their case, and the other defends.  It is an enquiry.  The Coroner therefore directs the proceedings and decides what evidence and what questions are helpful to the task of enquiring into the circumstances of the death.

The Coroner should be addressed as “Sir” or “Mam”.  Assisting the Coroner at the inquest will be the Coroner’s Officer and a Court usher. In addition, those present will include those witnesses the Coroner considers should be called to give oral evidence and any experts. 

If called to give evidence, before answering a question a witness should ensure a clear understanding of that question.  If a question is not understood the witness should simply ask for the question to be repeated, or to be put in a different way. A witness should not answer a question that they do not understand, and a witness should restrict their answer to the question actually put, and not what they imagine has been put, or what they will have liked to have been put to them.

If English is not  your first language and you are the witness or the next of kin you need to inform that Coroner’s Officer before the Inquest date and they may be able to organise an interpreter for you.


There are a number of possible findings (previously called verdicts) depending on the factual evidence, namely:

  • Accident or misadventure
  • Alcohol drug related
  • Industrial disease
  • Lawful/unlawful killing
  • Natural causes
  • Open finding
  • Want of attention at birth
  • Suicide
  • Road traffic accident
  • Stillbirth
  • Neglect
  • Narrative finding
  • Self neglect


The Coroner has an important role in trying to prevent further deaths. The Coroner may make recommendations to bodies such as the NHS to improve on protocols/guidelines and other procedures relevant to patient care. In such a case the Coroner will report the matter in writing to the person or authority who may have the power to take such action.  The Coroner’s Rules stipulate that “no verdict can be framed in such a way as to appear to determine any question of criminal liability on the part of a named person, or civil liability”, but in rare circumstances a Coroner may refer a matter to the Criminal Prosecution Service.

The Coroner must provide an interested person and the Chief Coroner with a copy of his recommendations.

Other useful resources

If you would like more in depth information about inquests the following resources/organisations may be helpful:

The Encephalitis Society is the operating name of the Encephalitis Support Group which is a registered Charity and Company Limited by Guarantee.

Registered in England and Wales No. 4189027. Registered Office as above. Registered Charity No. 1087843.