Coping with a sudden loss is challenging. Trethowans are able to advise and represent bereaved families at inquest, following the death of a relative.

An inquest is a fact-finding exercise which explores when, where, how and in what circumstances someone has died.

Inquests are conducted in the Coroner’s Court by a coroner and, in some cases, in front of a jury. The proceedings are non-adversarial – i.e. there are no parties, and no pleadings or allegations. The purpose is not to apportion blame on anybody or any organisation.

When is an inquest necessary?

An inquest is held in cases where the death:-

  • was unnatural or violent;
  • when a person was in state detention (including prison/police custody, detention under the Mental Health Act); or
  • when the cause of death is still uncertain after a post-mortem.

It is usual for the coroner to hold an inquest when a death occurs within 24 hours of admission to hospital or after a surgical procedure, although this is not mandatory. If there is a possibility that a medical procedure contributed to or caused the death, it should be discussed with the coroner, regardless of the timescales involved. Details of the referral to the coroner should be recorded in the patient’s medical records.

The coroner may also hold an inquest if the death was due to natural causes and an inquest is considered by the coroner to be in the public interest.

What happens at an inquest?

An inquest is a public hearing. Unlike a criminal court case, there is no prosecution or defence. The coroner presides at the inquest and decides which witnesses they wish to hear from.

The coroner will request written witness statements which can be read out in court, or the coroner can call witnesses to attend and give oral evidence. Family members and other “interested persons” are permitted to ask questions of the witnesses called by the coroner.

Some witnesses may be asked to produce a report. The report will be made available in court and questions can be asked by interested persons.

It should be noted that it is not a function of the coroner to apportion blame. Therefore, any questions must be confined to the investigation and inquiry into the death and cannot be cross-examining. A witness is not obliged to answer any questions if the answer would incriminate them.

All witnesses and interested persons have the right to legal representation at the inquest.

Jury inquests

A jury will usually be appointed if the inquest is regarding a death whilst under state detention (including detention under the Mental Health Act), an industrial accident or poisoning, or following an act of terrorism. It will also be appropriate where deaths occurred in circumstances that, if repeated, could prove prejudicial to public safety (for example, a train or aeroplane crash).


At the end of the inquest the coroner will deliver a conclusion (it is no longer referred to as a “verdict”). It is now common for a coroner to deliver a narrative conclusion, which sets out the circumstances by which the death came about. However, there remain a wide range of “short form” conclusions open to the coroner which can be used, or which can be referred to as part of a narrative conclusion. These include:-

  • Natural causes;
  • Accident or misadventure;
  • Suicide;
  • Unlawful killing;
  • Neglect;
  • Open (meaning there is insufficient evidence to decide how the death occurred – the case is left open in case any further evidence is found).

The coroner cannot decide any issues of medical negligence; however the phrase “aggravated by self-neglect or lack of care” can be added to the added to the first three short form conclusions (above) if it is deemed appropriate. This could have implications for any healthcare professional involved in separate civil proceedings.

The standard of proof applied at an inquest is the civil law standard – on the balance of probabilities. The coroner (and jury) must be sure that, it was more likely than not that the proven facts support the conclusions. Recent cases have also made clear that the civil law standard applies to conclusions of suicide and unlawful killing, whereas previously these conclusions were based upon the criminal law standard (i.e. beyond all reasonable doubt).

After the inquest

A final death certificate is made available following the inquest.

The coroner has a duty to write a report in cases where the evidence suggests that future preventable deaths could occur and that, in the coroner’s opinion, preventative action should be taken. The report is sent to the person or authority with the power to take the appropriate steps to reduce the risk, and they have a duty to reply within 56 days.

The coroner’s verdict can only be challenged by judicial review in the High Court. Such a challenge has to be brought within 3 months of the conclusion of the inquest.

The coroner does have the power to refer a doctor or healthcare professional to their regulatory body if they consider that it may prevent a recurrence of the incident or circumstances which caused the death.

Representing you at inquests

Trethowans are able to advise bereaved families as to the inquest procedure, and provide full representation at any pre-inquest hearing and at the inquest itself. Contact us today on 0800 2800 421 to arrange a consultation with one of our experienced inquest lawyers.

Meet the team

Tom Hartigan


Emily Thompson

Trainee Solicitor