What is an Inquest?

An inquest is an investigation to find out how someone came by their death. It is led by a coroner whose role is to answer four main questions:

1. The name of the deceased
2. The place of their death
3. The time of their death
4. How the death occurred

The Coroner also has a duty to consider whether it is necessary to submit a Prevention of Future Deaths Report, if there is anything that arises during the course of an Inquest that leads the Coroner to suspect that future deaths may occur unless action is taken.

Why is an Inquest held?

A coroner must conduct an investigation into a person’s death if they have reason to suspect that:

a) the deceased died a violent or unnatural death,
b) the cause of death is unknown, or
c) the deceased died while in custody or otherwise in state detention.

What is the purpose of an inquest and can an Inquest find blame?

The purpose of an inquest is to find out how and in what circumstance the deceased came about his or her death.

Aston Knight Case Study

Inquest into the death of a 40 year old son

Mr L attended North Manchester General Hospital for what should have been routine abdominal surgery.  Whilst surgery appeared to be successful, his family noticed a dramatic deterioration in his condition over the ensuing weekend, in which he remained an inpatient.  Despite his apparent substantial deterioration the attending healthcare staff took no meaningful action until the early hours of the following Monday morning, by which time he was gravely ill and passed away during resuscitation attempts.

A post-mortem revealed there had been a leak in his bowel following the surgery, which explained his deterioration following.  Mr L’s parents instructed Aston Knight Solicitors, both in relation to the Inquest and also the following clinical negligence civil claim.  Despite the Trust having held its hands up to a degree in a complaint response prior to the Inquest, appallingly, during the Inquest they (perhaps under the influence of their legal representatives) tried to defend their position and to argue that their negligence had not caused his death.

In representing the family over a two and half day Inquest we introduced witness evidence to prove how substantially Mr L had deteriorated and the Coroner held that the delay in his treatment had contributed to his death.

The Coroner expressed that the family had been very well represented and we were proud to have assisted the family and to have then proceeded to succeed in a civil clinical  negligence claim following.

The inquest is concerned only with determining the cause of death. It is not directly intended to apportion blame or consider issues of civil or criminal liability and no compensation can be recovered directly through the inquest process.

A fatal claim can either be brought after an inquest, or it can be brought in circumstances where no inquest was held, as a standalone claim.

The claims process is intended to provide compensation when someone has died as a result of negligence. To succeed with a fatal claim it has to be proven that the care/treatment was not appropriate and that the substandard treatment caused or contributed to the person’s death.

Where an inquest has been held, and evidence suggests that there was substandard treatment which caused the death, then a claim may be brought following the inquest.

What happens at an inquest?

In the lead up to the Inquest, the Coroner’s Officer will liaise with all Interested Parties, which includes family members and, sometimes, friends of the deceased.

There may be a pre-inquest review hearing. This is a hearing where the coroner will plan for the arrangements of the inquest. This will likely focus on what documents and evidence is needed for the inquest, which witnesses need to prepare statements and appear at the inquest itself, and practical issues such as the length and date of the inquest.

The Inquest itself is usually held at the Coroner’s Court in the geographical area in which the death occurred but this is not always the case and the Coroner’s Officer will confirm the details well in advance of the Inquest start date.

The evidence will be heard by the Coroner and/or the Jury at the Inquest, either by statements being read out in Court or by witnesses attending in person and answering questions under oath.

The Coroner may decide that some evidence is not required at the Inquest because it does not assist in determining who the deceased was and how, when and where they came by their death. It is the role of the Coroner’s Officer to explain who will be required to attend in person to give evidence and whose statements will be read out. Interested Parties are invited to ask questions about the evidence but it must be remembered that the purpose of the Inquest is narrow, as outlined above. Witnesses can be stopped from answering any questions that stray outside this narrow scope i.e. questions that seek to attribute blame that could lead to a criminal or civil liability.

Once all the evidence has been heard and any questions from the Interested Parties answered, the Coroner or Jury will need to time to consider all the evidence and will make a determination about who has died, where, when and how they died. Findings will also be made to assist with the recording of the cause of death. This can sometimes happen on the day but, particularly in cases involving complex issues and multiple witnesses, the Coroner or Jury may make a determination on another day.

How long do inquests last?

The Inquest can last for part of a day, for several days or occasionally several weeks or months.

Aston Knight Case Study

Inquest into the death of Baby D.

Negligently, the baby’s mother had not been offered the Whooping Cough vaccine, despite this being required under national guidance.  As a consequence her baby contracted Whooping Cough and tragically died a number of days later.

We represented the parents over a four day inquest, including a pre-inquest review hearing, at Doncaster Coroner’s Court.  The Inquest was complex, involving a number of hospital trusts and also their GP surgery.  In the course of the Inquest not only did the GP surgery admit failing to notify patients about the need for the vaccine but, more crucially for the case, the Coroner made a finding of fact that the community midwife, who worked out of the GP surgery but on behalf of the local hospital trust, failed to provide the required standard advice about the need for the vaccine.  This factual finding meant it would be impossible for the Trust to defend a clinical negligence case which we also went on to succeed with.

Whilst it was a very emotionally challenging process, both parents were relieved that the Coroner ruled in their favour regarding the failure to advise about the vaccine.

Who can attend an inquest?

Inquests are held in open court, which means that any friends and family of the deceased can attend. The coroner will often require one particular member of the family to attend. The media/press can also attend. Witnesses (for example a doctor, police officer or eyewitnesses) may attend to give evidence. The coroner decides who to call.

What happens after an inquest?

At the end of the inquest, the coroner will give his/her conclusion and this will appear on the final death certificate. The death can then be officially registered. The conclusion cannot (in most circumstances) include any suggestion of blame.

What findings can a Coroner or Jury make?

There is no definitive list of conclusions available to a Coroner. The following are those most commonly used:

• natural causes (including fatal medical conditions);
• accident or misadventure;
• industrial disease;
• dependence on drugs/non-dependent abuse of drugs;
• attempted/self-induced abortion;
• disasters subject to public inquiry;
• lawful killing (such as deaths caused during acts of war, or self-defence);
• unlawful killing;
• suicide;
• open verdict (where there is insufficient evidence for any other verdict).

How we can help?

We have a wealth of experience in assisting those affected by a sudden death leading to an inquest and will provide you with the professional support and advice you need to get through this difficult time.

We can liaise with all the relevant people and authorities on your behalf; including the Coroner’s office, the Prison Service, the Police, the Prison and Probation Ombudsman, NHS or MOD and request that you have access to all the relevant material prior to the hearing. This may included ensuring you get disclosure of post mortem examination reports, expert reports, medical records and other documents relevant to the death.

We deal with a wide range of inquests including deaths in prisons, hospitals, care homes and military deaths, including representing families at the following inquests:

• Inquest into the death of Mr B who was found to have died of mesothelioma
• Inquest into the death of two SAS soldiers who died as a result of an RAF helicopter crash in Iraq.

If you are unsure whether you need representation, please get in touch with us on 0161 399 1231 and we can discuss this with you further.

Inquest representation can often be arranged at no cost to you, either through Legal Aid or through a ‘no win, no fee’ agreement where there may be a claim against an organisation that was involved in the death of a loved one after the inquest.

By Emma Pearce, Solicitor