Inquest What And Why

What is an Inquest?

An inquest is a limited, fact-finding enquiry to establish who has died, how, when and where the death happened. The Coroner does not seek to establish issues of liability.  Inquests do not have prosecution and defence teams, as a criminal trial would;  the coroner and all those with “proper interests” simply seek answers to those questions.

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An inquest is usually opened soon after a death to record that the death has occurred, to identify the deceased, and to enable the coroner to issue the authority for the funeral to take place without any unnecessary delay.      It will then be adjourned until any other investigations and any enquiries required by the coroner have been completed. This will take an average of just over six months, sometimes longer if the enquiries prove complex. Once enquiries are concluded, the inquest will then be resumed and concluded.

The coroner may hold hearings before the inquest itself, where the scope of the inquest and any matters of concern, including arrangements for the hearing, can be considered. The coroner usually invites properly interested persons and/or their legal representatives to the pre-inquest hearing, where they have the opportunity to make representations to the coroner.

What happens if somebody has been charged with causing the death?

Where a person has been sent for trial for causing, allowing or assisting a death, for example by murder or manslaughter, any inquest is in most cases adjourned until the criminal trial is over. On adjourning an inquest, the coroner must send the Registrar of Births and Deaths a certificate stating the particulars that are needed to register the death and for a death certificate to be issued. When the trial is over, the coroner will decide whether to resume the inquest. There may be no need, for example, if all the facts surrounding the death have emerged at the trial. If the inquest is resumed, however, the finding of the inquest as to the cause of death cannot be inconsistent with the outcome of the criminal trial.

Attending an inquest

When a coroner’s investigations into a death are complete, a date for a full inquest will be set. The properly interested persons (essentially the relatives and others closely connected  with the deceased) will be informed of the date and time by the coroner’s officer and any witnesses will be asked to attend to provide evidence. The process is held in the public interest and not on behalf of any individual. It is not always necessary for the bereaved relatives to attend the inquest, and some prefer not to, as the details of the death may need to be dealt with in graphic terms. If bereaved relatives do wish to attend the inquest they can be accompanied by a supporter, for example a friend.

Is there always a jury at an inquest?

No, most inquests are held without a jury, but there are particular circumstances when a jury is called, including:

  • if the death occurred in prison or in police custody; or
  •  if the death resulted from an accident at work.

In every jury inquest the coroner decides matters of law and procedure and the jury decides the facts of the case and reaches a verdict. The jury cannot blame someone for the death. If there is any blame, this can only be established by other legal proceedings in the civil or criminal courts, although the jury can state facts which make it clear that the death was caused by a specific failure of some sort or by neglect.

Who decides which witnesses to call?

The coroner will decide who should be called to give evidence as a witness and the order in which they give evidence.   However, anyone who believes they may be of help or believes a particular witness should be called should inform the coroner. The coroner will then decide whether the evidence is relevant to the investigation of the death.

Must a witness attend an inquest?

Yes, if they live in England or Wales. In many cases the evidence of a witness may be vital in establishing the facts of the death. A witness may either be asked to attend the inquest voluntarily or receive a formal summons to do so, but if they live abroad they cannot be compelled to attend or to give evidence.

Who can ask witnesses questions?

Witnesses will be first questioned by the coroner and then additional relevant questions may be asked by any properly interested person or their legal representative. Whether a question is relevant to the purpose of the inquest is something the coroner decides. Where relevant, the coroner will warn a witness that he or she is not obliged to answer any question which might incriminate him or herself.

Is Legal Aid available?

Legal Aid is not generally available for representation at inquests because an inquest is a fact-finding process. Unlike other proceedings for which Legal Aid might be available,  there are no parties in inquests, only the properly interested persons, and witnesses are not expected to present legal arguments. The coroner ensures that the process is impartial and thorough, and he or she should assist families to ensure that their relevant questions are answered.

Legal Aid may, however, be available to cover representation at the inquest in very exceptional cases. Generally, applicants must qualify financially and applications must meet strict criteria for representation to be funded. These criteria are that:

  • there is a significant wider public interest (as defined in the Legal Services Commission’s Funding Code) in the applicant being represented at the inquest; or
  • the applicant is a member of the deceased’s immediate family and the circumstances of the death appear to be such that funded representation is likely to be necessary to enable the coroner to investigate the case effectively and establish the facts (as required by Article 2 of the European Convention on Human Rights).

Legal advice and assistance – via the Legal Help scheme –  is available to those who qualify financially. Further information about solicitors who carry out legal aid work can be found in the  Community Legal Service directory on 0845 345 4345 or at

Inquest conclusions

Possible conclusions as to how the death occurred as suggested by the Coroners Rules 1984 include:

  • natural causes;
  •  accident or misadventure;
  • he or she killed him/herself (i.e. suicide);
  • unlawful killing;
  •  lawful killing;
  •  industrial disease; or
  •  open verdict (where there is insufficient evidence for any other verdict).

Alternatively, the coroner can give a narrative verdict which sets out the facts surrounding the death in more detail and explains the reasons for the decision.

It is possible to challenge a coroner’s decision.

What if future deaths may be prevented?

One of the great services coroners do for us is when sometimes an inquest will show that something could be done to prevent other deaths. If so, at the end of the inquest the coroner may announce that he or she will draw this to the attention of any person or organisation that may have the power to take action.  Anyone who receives such a report must send the coroner a written response. These reports and the responses to them are copied to all properly interested persons and to the Lord Chancellor. A summary is published twice a year, by the Ministry of Justice.

Will the inquest be reported by the media?

All inquests must be held in public in accordance with the principle of open justice, and so members of the public and journalists have the right to, and indeed may attend (although parts of a very small number of inquests may be held in private for national security reasons). Whether journalists attend a particular inquest – and whether they report on it – is a matter for them. If any such report is fair and accurate it cannot be used to sue for defamation.   Those working on newspapers or magazines must abide by the relevant Code of Practice.

Suicide notes and personal letters will not usually be read out at the inquest unless the coroner decides it is important to do so. If they are read out, their contents may be reported.  Although every attempt is made to avoid any upset to people’s private lives, sometimes, in the interest of justice, it is unavoidable. Photographs taken of the deceased and of the scene of death may also form part of the evidence presented.

What about other proceedings?

Any civil proceedings will normally follow the inquest. When all the facts about the cause of death are known it is possible that civil proceedings may be brought and a claim for damages made. A lawyer’s advice should be sought about the time limits and procedures that apply. Inquest evidence cannot be used directly in other proceedings.

Further information

The Metropolitan Police Bereavement Information Line (a recorded message) on 0800 032 9996, is on 24 hours a day or see

More on the role of the coroner.

Back to what to do on death.

Inquests.  Bereavement help