A guide to an Inquest

This guide is prepared to assist the lay person to navigate the complexities of an inquest but it is not suitable for cases involving matters of national security, military death or Article 2 Human Rights issues that require more detailed guidance than can be given in this short booklet. This guide is no substitute for taking formal legal advice on a particular matter and no liability can be attached to the author for relying upon the same.

The coroner

The role of the coroner is to investigate violent or unnatural deaths and those deaths which are known to have occurred in state custody or detention.

The coroner will not determine either civil or criminal liability. The inquest should not be perceived as a “fault finding” forum but instead one of investigation to determine the factual issues.

The coroner is assisted by the coroner’s officer who is usually the first individual to be notified of the death prior to the inquest beginning, and often the correspondence to the interested parties will be with the officer. The coroner’s officer will collate any evidence for an inquest, for example police reports, pathology reports.

When a coroner accepts responsibility over a body he can insist on a post-mortem being carried out. The coroner has a duty to inform interested parties if there is to be a post mortem, and if so the coroner will appoint an independent pathologist. The pathologist will prepare the post-mortem report that is delivered to the coroner. Any interested party may apply to the coroner for a copy of the post-mortem report. The coroner must release the body at the earliest opportunity once any investigation concerning the body is completed.

Who is an interested party

The coroner will rule upon who is an interested party. An interested party must have a genuine desire to participate in the proceedings. As an example, if the death occurred at work due to an alleged defective ladder then those who may be granted interested party status are the next of kin, the employer, the owner and/or manufacturer of the ladder. An interested party should be notified of the hearing inquest arrangements, provided with certain disclosure documents, and have a right to question witnesses.


The coroner will determine which witnesses will be called to give oral evidence at the inquest and whose evidence will be accepted in written format. The coroner’s officer will usually provide the interested parties with a list of witnesses who will be summoned by the coroner to attend.

Opening an inquest

The coroner must inform the next of kin of the decision to begin an investigation into the death and must open the inquest in public as soon as possible. This normally takes place a few days after the death, formal evidence of identification is given, and interim certificate of the fact of death is given that will enable the next of kin to progress the estate arrangements, for example apply for a Grant of Probate. The coroner can then release the body to the family. The coroner will then list a pre-inquest review hearing and possibly set the date for the inquest.

Whether to hold an inquest hearing

The coroner may not commence inquest proceedings if he concludes from the evidence that there is no duty to investigate the death, or after investigation (perhaps from the post mortem or autopsy report) it appears that death was due to natural causes. As mentioned above, the role of the coroner is to investigate violent or unnatural deaths and those whose cause is known to have occurred in state custody or detention.

The coroner will also suspend the investigation or the inquest where there are possible or actual criminal proceedings, where there is to be a public inquiry under the Inquiries Act 2005, and in any case where it is appropriate.

The pre-inquest review hearing

The coroner has the discretion to hold an early hearing, called “pre inquest review hearing”. This is usually a relatively short hearing held in public to allow the coroner to consider what is required for an inquest if one is to be held. At this hearing there is consideration of documents, witnesses, and whether a jury will be required. In advance of the hearing, the coroner would usually provide the interested parties with an agenda giving them the opportunity to submit in advance written submissions that can be considered at the hearing.


Not all coroners have a dedicated court building to hold inquests therefore an interested party who wishes to attend a hearing should check with the coroner’s officer the

address for the hearing. The geographical location of the inquest will usually be where the body was taken unless there is good reason to transfer the responsibility to another coroner in a different location. The coroner will consider the location of any witnesses and interested parties who may need to attend the inquest.

The layout of the inquest room will also vary depending upon the venue. Any legal teams would often sit at the front with the bereaved family and other interested party behind. Any witnesses summoned by the coroner to give evidence will also usually remain in court and hear the evidence unless the coroner directs otherwise.

It should be noted that the public and media are normally admitted to the inquest. The bereaved family should be prepared for any approach by the media and may wish to gather their thoughts beforehand, for example prepare a written statement for the media.

There is no set dress code for the inquest. The legal representatives will often confirm with the coroner’s officer beforehand as to any particular preference of the coroner but for the bereaved families and others attending it would be suggested a lounge suit is worn or smart clothes.

The purpose of the Coroner’s Court

The purpose of an investigation into the death is to determine:

  1. Who was the deceased;
  2. How the deceased came by their death;
  3. When the deceased came by their death;
  4. Where the deceased was when they came by their death;
  5. Ascertaining in what circumstances the deceased came by their death

It is for the coroner to decide which “witnesses” it is expedient to examine. At the inquest the coroner shall disallow any question which in his opinion is not relevant or is otherwise not a proper question.

The inquest is a fact-finding, non-adversarial inquiry. The coroner will not consider criminal liability on the part of a named individual or civil responsibility Jury.

The vast majority of inquests are heard before a coroner without a jury and concluded within one day. The coroner has a discretion to call a jury and determine which issues to be put to the jury. However, if the death resulted in an investigation by the Health & Safety Executive or a death in police custody then the inquest must be heard before a jury, and will usually last several days if not weeks.

Who can attend the inquest?

The inquest is normally a public forum therefore anyone may attend to observe but only those who are classified by the coroner as an “interested party” may put questions. Whilst it is intended for the “lay” or unrepresented person to be able to attend the inquest as an interested party to put forward questions it should be borne in mind in cases where the death occurred through someone else’s alleged fault then that party may well be represented by a legal team, normally a Barrister, appointed by their insurance company.

The coroner will summons all witnesses that are to give oral evidence to attend the inquest.


As a matter of practice the coroner will begin the inquest by asking questions first of a witness, followed by the questions of interested parties, it will be perfectly permissible for parties to ask questions of a witness which may flow from the coroner’s examination. The coroner may limit the types of questions asked if it deviates from the inquest purpose. It should be remembered this is not a fault finding forum.

The coroner can permit a witness to give evidence by video link or behind a curtain.

Disclosure of documents

Pre-inquest disclosure of documents to interested parties will be on a confidential basis, purely for the purpose of enabling interested parties to prepare for the inquest. Likewise, if an interested party has a document that may be pertinent to the inquest then that should be disclosed to the coroner as well as any other interested party. This would include for relevant witness statements.

The coroner has no power to order the police to disclose documents or statements but it would be unusual for the police not to reasonably co-operate. The disclosure will usually take place once any police or HSE prosecution has concluded to avoid prejudice to those separate proceedings. The documents disclosed can be redacted if it is necessary to protect the identity of a person or persons.

If during the Inquest it becomes apparent that disclosure of a material document has not taken place that is relevant to the proceedings then the coroner does have the power to adjourn the inquest.


Whether a coroner calls an expert witness depends on the circumstances of the individual case including the issues to be investigated and the coroner’s own expertise as well as the availability of other evidence. If a coroner does not call an expert witness then an interested party could obtain their own expert evidence which they would then invite the coroner to accept into evidence. The expert then becomes the coroner’s expert and the report is made available to all interested parties. In cases of road death it is usual for the police collision investigator to attend, and in cases where the HSE have investigated, it is usual for their report to be submitted into evidence.

The determination and findings (the verdict)

The coroner, whether or not with a jury, must answer five questions:

  1. The name of the deceased (if known);
  2. The injury or disease causing death;
  3. The time, place and circumstances at or on which injury/death was sustained;
  4. The conclusion of the jury or the coroner as to the cause of death;
  5. The particulars required to register the death

Conclusions available (at 4 above):

  • Accident or misadventure
  • Alcohol or drug related
  • Industrial disease
  • Lawful or unlawful killing
  • Natural causes
  • Open
  • Road traffic collision
  • Still birth
  • Suicide


A coroner, who believes that action should be taken to prevent further fatalities similar to that in respect of which the inquest is being held is under a duty to make a report to prevent further deaths. This report can be sent to a person or authority who in his opinion should receive it, and state when a response should be received. As an example, a coroner who has heard an inquest involving a road death may write to perhaps the police or highway authority in an endeavour to prevent further road death at the same location if it is believed the road layout needs to be reviewed.


There is no right of appeal from the decision of a coroner. There is only the possibility of seeking judicial review that must be commenced within 3 months of the cause.

Legal costs

If you do seek legal representation then a solicitor will investigate with you the best way to fund representation at the inquest, including:

  1. Whether trade union funding is available;
  2. Whether the matter can be funded privately;
  3. Whether there is legal expenses insurance available;
  4. Whether the solicitor can act for you under a “no win, no fee” basis Community Legal Service funding (legal aid) is not widely available for inquests but enquiries should be made.

Contacts for counselling and bereavement services:

0845 4500 355

0808 800 0401

0808 808 1677

Child Bereavement UK
0800 02 888 40

Inquest helpline: 0800 157 7611