Encyclopaedia


Inquest

Introduction

A coroner's court is a legal body that is established to determine how, when and why a person died. In some cases, a coroner’s court will also attempt to determine the individual's identity. The process of determination is known as an inquest.

The Coroner's Court holds an inquest when the cause of a person's death remains in doubt, even after a post- mortem.  A post-mortem is an examination of the body after death that is carried out by a pathologist (a doctor who specialises in medical diagnosis). It is also known as an autopsy.

Coroners are independent judicial officers. Coroners are usually lawyers but in some cases they may be doctors. They investigate violent, unnatural or sudden deaths where the cause of death is unknown.

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When should it be done?

In most cases, when someone dies, a GP or the hospital doctor who was treating the deceased can certify the medical cause of death, which is then registered by the Registrar of Births and Deaths.

A death occurring in the following situations is reported to the coroner by the police or by the doctor who was treating the deceased.  The Registrar may also report a death to the coroner and must await the coroner's report before registering the death.

  • When the doctor attending the patient had not seen them within 14 days before or after death.
  • The death was violent or unnatural, or occurred under suspicious circumstances.
  • The cause of death is unknown or uncertain.
  • The death was caused by an industrial disease or related to the deceased’s employment or to an accident, violence, neglect, abortion, or poisoning.
  • The death occurred in prison or in police custody.
  • The deceased was detained under the Mental Health Act.
  • The death may have been contributed to by the actions of the deceased for example, an overdose, self-injury or drug abuse.
  • The death took place within 24 hours of admission to hospital.
  • The death may have been related to a medical procedure or treatment.
  • The death occurred during an operation or before recovery from the anaesthetic.
  • No doctor attended the deceased during his or her last illness.

In the above cases, the coroner may arrange a post-mortem to be carried out. The coroner will then arrange an inquest, unless the post-mortem showed that death was due to natural causes or established the cause of sudden death.

In 2008, 47% of deaths in England and Wales were reported to the coroner. Almost all of the cases (46%) underwent a post-mortem.  Approximately 13% of reported deaths resulting in inquests.

The purpose of an inquest is not to find out who is to blame for the death, but to establish the facts surrounding the death, including who has died and how, when and where the death occurred. An inquest is not a trial and it is not the coroner’s responsibility to place blame on any individual for a person’s death.

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How is it performed?

Most inquests are carried out by the coroner alone. However, there are some circumstances when the coroner is required to call a jury for the inquest. A jury is required when:

  • The death occurred in prison, police custody or resulted from an injury caused by a police officer.
  • The death was caused by an accident, poisoning or disease in circumstances which are legally required to be reported to the government (such as a road traffic accident, an industrial accident or railway accident).
  • The death occurred in circumstances that could have a detrimental effect on the health and safety of the public.
  • The death resulted from an accident at work.

The coroner can also call a jury at their own discretion.

A coroner's inquest does not apportion blame to any individual. During an inquest, the coroner can call upon all witnesses who have relevant information concerning the inquiry. It is up to the coroner to decide whether the information given is relevant to the investigation.

Proper interest

Anyone who has a 'proper interest' may question a witness at the inquest. A ‘properly interested’ person is defined as:

  • a parent, spouse, child, civil partner and anyone acting for the deceased
  • anyone who gains from a life insurance policy of the deceased
  • any insurer who has issued such a policy
  • anyone whose actions the coroner believes may have contributed to the death accidentally or otherwise
  • the chief officer of police (who may only be asked questions through a lawyer)
  • any person appointed by a government department

The coroner will decide who is given proper interest status.

When someone is charged with causing the death

If an individual has been charged with causing someone’s death, the inquest will be delayed until the individual’s trial has been completed. Before the delay, the coroner will determine who the deceased was and how they died. They will then complete a form and send it to the registrar of deaths so that the death can be registered. Once the trial is over, the coroner will not usually continue the inquest.

Coroners and Justice Act 2009

The Ministry of Justice (MoJ) and the Department of Health (DH) introduced the Coroners and Justice Act in November 2009.

The Act includes measures to:

  • create a new national coroner service which is led by a new chief coroner
  • create a new system of certification of deaths that are not referred to the coroner, covering burials and cremations
  • deliver more effective justice and coroner services for victims, witnesses, bereaved families and the wider public
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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.

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