Inquests

If your relative dies there may be an inquest into their death. This section explains what an inquest is, what it will be like and your rights during the investigation. It covers every stage from the first investigation to appealing the conclusion of an inquest. The headings will guide you to the information you may need at each stage of the inquest.

This section has a lot of information. It may be overwhelming to try and read all of this at once.

***** New emergency coronavirus legislation has been introduced. It means that there are some temporary changes to some of the information included below. You can read about the changes by clicking here. *****

Overview

  • If your relative dies in certain situations, a doctor will report their death to the coroner.
  • The coroner’s job is to find out who died, when, where and the cause of death.
  • The coroner will investigate the death. They may ask for a postmortem examination or hold an inquest.
  • An inquest is a public investigation. The coroner is in charge of it. An inquest will happen if they don’t know how your relative died or if their death was unnatural.
  • The coroner will not investigate all deaths.
  • If your relative died in a psychiatric ward, prison or in police custody, there may need to be a wider Article 2 inquest.
  • Coroners should keep you involved. They should tell you about the inquest and post-mortem arrangements.
  • If you are a parent, child, spouse, civil partner or partner of someone who has died, you can register as an interested person. This means you can ask questions at the inquest.
  • If the coroner holds an inquest, there may be a jury.
  • At the end of the inquest, the coroner or jury will give a conclusion of how they think your relative died.
  • You may disagree with the coroner’s decision not to hold an inquest or the conclusion of an inquest. You can only challenge this through applying to the High Court.

Initial information

What happens after my relative has died?

Doctors, the police and registrars of births and deaths will report certain deaths to a coroner.

Deaths that are reported to a coroner include the following:

  • the cause of death is unknown,
  • the death was violent or unnatural
  • a doctor hasn’t been able to complete a death certificate, or
  • there are concerns about the cause of death.

You or anyone else can report a death to a coroner if you are concerned about it.

Will the coroner investigate the death?

The coroner’s team will talk to relevant people to gather information about your relative’s death. For example, they may talk to your relative’s doctor. Not all deaths which are investigated will need to have an inquest. You will be told if an inquest is needed.

Death that isn’t investigated
An investigation, also known as an inquest, won’t happen if the doctor confirms that the death happened because of:

  • natural causes, or
  • a medical condition, and
  • there are no unusual circumstances

If this happens:

  • the doctor will sign a medical certificate
  • you will take the medical certificate to the registrar
  • the coroner will issue a certificate to the registrar to confirm that a post-mortem is not needed.

Death that is investigated
The coroner must investigate a death, known as an inquest, if they think that:

  • someone died a violent or unnatural death,
  • the cause of death is unknown, or
  • someone died in prison, police custody or state detention.

State detention includes people in immigration detention centres. And people detained in hospital under the Mental Health Act.

People and processes involved

What is a coroner?

A coroner is a judge appointed by the local authority, but they don’t work for them. This means that they are independent. They investigate certain deaths that happen in their local area.

A coroner is usually a legal professional. But sometimes they are doctors. The coroner will be part of a service with other employees called ‘coroner’s officers.’ They are the link between you and the coroner. Most of your contact will be dealt with by the coroner officers.

Coroner’s officers are usually civilian police officers or local authority employees. They help with:

  • information gathering, and
  • talking to family, police and other relevant professionals.

What does the coroner do?

The coroner has to find out:

  • the identity of the person who has died,
  • when and where they died,
  • how the person died, and
  • any other details needed to register their death.

The coroner will also use any information discovered during the investigation to help prevent other deaths where possible.

What is a post-mortem examination?

A post-mortem examination, or post-mortem, is a medical examination of your relative’s body to find out the cause of their death. Sometimes it is called an autopsy. A post-mortem will happen as soon as possible following your relative’s death.

When a coroner arranges the post-mortem, this is carried out by an independent medical professional such as a pathologist. A pathologist is a specialist doctor who can examine your relative’s body organs, tissues and fluids. They do this to find out how they died.

The coroner may ask the pathologist to test your relative’s body for certain substances. They may want to know about any medication, illegal drugs, alcohol or other substances in your relative’s body. This is called a toxicology report.

Sometimes they will keep small samples of your relative’s tissues or organs. This is in case they need to do more tests. There are strict rules about this.

They can only keep tissues or organs that are relevant to the post-mortem. The coroner must tell you if they do this. In some cases, such as murder, the tissues or organs may have to be kept for a long time.

Once they have finished the tests you can:

  • ask them to dispose of it,
  • ask them to return it to you, or
  • agree for them to keep it for medical research or other purposes.

Do I have to agree to a post-mortem?

A coroner can ask for a post-mortem on your relative without your agreement.

You may have cultural or religious reasons for not wanting a post-mortem. You can discuss these with the coroner’s office.

If the coroner still thinks that a post-mortem is necessary, you have to take legal action to try and stop it.

This is called a judicial review. You can only ask for a judicial review if the coroner’s decision is unreasonable. You need specialist legal advice for a judicial review. Post-mortems usually happen soon after someone has died so you may not have time to get this advice.

Can I go to the post-mortem?

You cannot usually go to the post-mortem, but you can have someone represent you. You should tell the coroner’s office if you want a representative to go. Then someone from the coroner’s office must tell you when and where it will be.

A doctor could represent you, but they may charge you for this. If you are medically qualified you can go to the post-mortem.

Other people who can go to your relative’s post-mortem include:

  • your relative’s GP,
  • someone from the hospital where your relative died,
  • the chief officer of police, and
  • anyone the coroner invites.

Can I see the post-mortem report?

If you are an ‘interested person‘ you can ask the coroner for a copy of the post-mortem report. There is more information about interested persons below.

It can sometimes take weeks or months to complete the final report. The coroner’s office will let you know of any delays. You may find it difficult to read the post-mortem report. It uses scientific language and it can be upsetting to read. Some coroners may send the report to your GP, who can help explain it to you. If you have a solicitor helping you with the inquest, you could ask them to read it for you.

Can I ask for another post-mortem?

You can ask for a second post-mortem if you are not happy with the result of the first one. You should discuss this with the coroner’s office. You will have to pay for the second post-mortem yourself.

What is an inquest?

An inquest is an investigation into the facts of how your relative has died. A coroner will look at different information and decide the cause of death.

The coroner will tell the next of kin, or the personal representative, when your relative’s inquest will take place. There is usually a hearing to ‘open’ the inquest first. This is a short hearing. The coroner will usually then pause the inquest until a later date. This is so that they can get all the information needed to investigate the cause of death.

When should a coroner hold an inquest?

The Coroners and Justice Act 2009 says that a coroner should hold an inquest when:

  • they were unable to find out the cause of death from the postmortem,
  • the death was found to be violent or unnatural, or
  • someone died in custody or state detention (this includes immigration detention centres, secure mental health hospitals).

What does an inquest cover?

The facts to be found out from an inquest are:

  • who died,
  • how, when and where someone died,
  • information needed by the Births and Deaths Registration Act 1953, and,
  • anything that happened which breached the European Convention of Human Rights (ECHR). This will usually mean Article 2 of the ECHR which is the right to life.

If there is any possible breach of human rights the investigation has to consider more events which might be relevant to their death. This is called an Article 2 inquest.

An Article 2 inquest must be held if your relative died in a psychiatric unit, and:

  • their death was violent or unnatural, or
  • the cause of their death is unknown.

This sort of inquest looks at wider questions about how your relative died. Article 2 inquests are discussed in more detail in the next section.

Can I ask questions at the inquest?

You can ask questions to the witnesses at an inquest if you are an ‘interested person’. You can also have a representative to ask your question for you. If you ask a question the coroner thinks is irrelevant, they can reject it.

What is an ‘interested person’?

An interested person is someone who has a specific interest in the investigation or inquest into. An interested person can be:

  • a close relative or the personal representative of the person who died,
  • professionals who may have some relation to the person who died, such as a representative for the police, NHS, medical examiner, government official, or
  • anyone the coroner feels has an interest.

Will the inquest find out who is responsible for my relative’s death?

An inquest is held to find out how, when and where someone died. It will not find anyone responsible for causing your relatives death.

An inquest may criticise certain things that someone did, or did not do, when looking at your relative’s death. But it can’t say that a particular person is responsible for their death.

What should I do if I think there should be an inquest into my relative’s death?

You might think that there should be an inquest into your relative’s death, but the coroner does not.

In this case you should tell the coroner as soon as you can after your relative dies. You can make contact by post or speaking to the coroner’s officer by telephone or email. It can help to keep things in writing.

You may want to get legal advice. If you do want to get legal advice you should do this as soon as possible. There is more information about this further down this page.

What is an Article 2 inquest?

An Article 2 inquest must be held if your relative died when they were in custody or state detention. This includes:

  • detained in hospital under the Mental Health Act,
  • police custody,
  • prison, or
  • immigration centre.

An article 2 inquest will still look at:

  • who died,
  • where they died,
  • when they died, and
  • how they died.

But it will also look at the broad circumstances of the death. This will include events that led up to the death.

The wider investigation has to happen to make sure that they meet their legal duty to comply with Article 2 of the European Convention of Human Rights. Article 2 is a right to life.

The investigation will be carried out by someone who was not involved with what happened to your relative.

The organisation INQUEST may be able to give you more information about an Article 2 inquest. Their contact details are in the useful contact details at the bottom of this page.

Most inquests are held without a jury. But Article 2 inquests must be held with a jury present.

If you think that Article 2 is relevant to your relative’s death, but the coroner does not agree, then you need to get legal advice. You may need a solicitor who specialises in Human Rights and Mental Health law. There is a list of organisations that can help you get legal advice in the Useful Contacts section at the bottom of this page.

Attending an inquest

Why would I go to my relative’s inquest?

The inquest can be a way of finding out about the events which may have led to your relative’s death. It can also help to answer questions you have about their death.

Inquests are open to the public, so if you aren’t an interested person you can still go to the inquest. Every coroner’s office will have the names and dates of when inquests are being held on their website. If you can’t find it on their website, you can ring the office and they will tell you.

When and where will the inquest be?

When will the inquest be held?

It varies. Inquests can be held a few weeks or a few years after the death. The main inquest hearing should normally take place within six months or as soon as possible after the death has been reported to the coroner.

If the situation is complicated it can take longer. For example, if there is a criminal case relating to your relatives death the coroner may have to wait until this is finished. This is especially the case if someone has been charged with murder or manslaughter.

Some inquests only take a few hours, but others can take several days or weeks. Article 2 inquests may take longer.

The Chief Coroner for England and Wales is responsible for preventing delays. If an inquest investigation takes longer than 12 months, it has to be reported to the Chief Coroner.

Where will the inquest be held?

Usually the coroner where your relative died will do the investigation. Sometimes the investigation is done by a coroner in a different area.

If an investigation is transferred to a coroner in a different area, the new coroner will let you know.

In large cities there will be a coroner’s court. Some towns and smaller cities have a coroner’s court but in many areas, this is not the case.

In smaller towns, the inquest may take place in a magistrates’ court or a room in town hall. Sometimes, a jury inquest may take place in a crown court.

Funeral delays

Will my relative’s funeral be delayed?

If a doctor, registrar or police officer reports your relative’s death to the coroner, then your relative’s funeral may be delayed.

Can I see my relative’s body while the coroner is investigating?

You can see your relative’s body if you would like to. You may be asked to identify the body as part of the investigation.

Sometimes the coroner may advise you not to see your relative’s body. It may be too distressing for you.

If you would like to touch your relative’s body, ask for permission before you visit. This may not be possible in some situations.

How long will it take the coroner to release my relative’s body?

When a coroner investigates your relative’s death, they have temporary control of their body. The coroner has to give permission for their body to be released. They will release your relative’s body when the pathologist has done all the medical tests they need. The coroner will usually release a body before they get the test results back.

There is no set time for when your relative’s body will be released. In more straightforward cases, it may be a few days. It can be longer in more complex cases or if there is a second post-mortem examination.

The coroner will release your relative’s body to the next of kin. If you think your family may disagree about who your relative’s next of kin is, you should contact the coroner.

When will I get a death certificate for my relative?

You need a death certificate to hold a funeral for your relative. You can ask the coroner to give you an interim death certificate.

You can also use the temporary death certificate to begin dealing with your relative’s estate, for example, closing bank accounts.

When the investigation or inquest is finished the coroner will confirm the cause of death to the registrar. The registrar will register the death. You can ask the registrar for a death certificate.

Preparation & rights

What do I need to think about before the inquest?

  • Can I get a copy of my relative’s health records?
  • What are pre-inquest reviews?
  • Who can be a witness and how do they give evidence?
  • How can i get a copy of the evidence before the inquest?
  • What are independent reports?
  • What if i think there has been clinical negligence?
  • Can i still make a formal complaint?

Can I get a copy of my relative’s health records?

You can apply for a copy of your relative’s medical records. This might be helpful if your relative was getting mental health treatment when they died.

These records may give you an idea of issues that might be relevant to the inquest. You may find it difficult or upsetting to read through these records. If you have a solicitor helping you with the inquest, you could ask them to read the records for you.

Confidentiality still applies for someone who has died. You can find out more information about ‘Access to health records’ by clicking here.

What are pre-inquest reviews?

The coroner may hold one or more pre-inquest review hearings.

At these hearings, the coroner and other interested persons decide about the practical arrangements for the inquest. This will include:

  • setting a date for the inquest,
  • how long the inquest will take
  • which witnesses the coroner will need to call, and
  • how wide the investigation will be.

You can go to these hearings if you want to. If you have a solicitor, they can go to these hearings for you.

Who can be a witness and how do they give evidence?

Witnesses are people who give evidence at the inquest. The coroner decides who should give evidence.

You can suggest witnesses that you think could be helpful or important.Contact the coroner to do this or ask your solicitor if you have one. The coroner does not have to call a witness if you ask for them to be called.

A witness can give evidence:

  • in person,
  • behind a screen, or
  • by video link, or
  • in writing.

The coroner can agree to written evidence when:

  • the witness cannot come to the inquest to give evidence at all, or within a reasonable time,
  • there is good reason why the witness should not come, there is a good reason to believe that the witness will not come, or
  • the coroner thinks most people will agree with the evidence.

Interested persons should be told who the evidence is from and what has been said before the coroner reads it out. Tell the coroner if you do not agree with it being read out in court. If you do not agree with the written evidence or do not agree to it being read out in court, then you can tell the coroner. The coroner will decide if the written evidence should be read out.

If you are asked to give evidence but think this will be too difficult you should discuss it with the coroner’s office. If they agree, you have a right to give a written statement instead which will be read out at the hearing.

How can I get a copy of the evidence before the inquest starts?

You will be given copies of documents that will be used in the inquest. This includes witness statements, medical reports and expert reports. If you do not receive documents that you think you have a right to, speak to the coroner’s office.

There may be documents that the coroner can’t give you for legal reasons. The coroner should explain why they haven’t given you a document. Or part of a document.

If you want copies of documents after the inquest has finished, you can be charged a fee.

What are independent reports?

The coroner can ask for a report by an independent expert. The type of expert they ask will depend on the issue. For example, if the coroner wants to know about your relative’s mental health treatment, they may ask a psychiatrist to write a report. If they want to know how hospital staff tried to resuscitate your relative, they may ask a specialist emergency care doctor for a report.

It can take some time for experts to write their reports. This can delay the inquest.

If you read an expert’s report, it may raise other issues or questions for you. You can ask the coroner about these issues.

What if I think there has been clinical negligence?

If you think that the death of your relative may be due to poor medical treatment you should contact a solicitor as soon as possible. You should do this even if you are already making a formal complaint.

Contacting a solicitor will not affect the complaints process. But it will mean that you get advice in good time for an inquest, if there is going to be one.

A lot of medical deaths do not have an inquest. If there is an inquest it only looks at limited issues. This means that the family and solicitor may have to convince the coroner to hold a full inquest. This can take a lot of work.

If you want to take legal action against a healthcare service, you need specialist legal advice. A clinical negligence solicitor will be able to tell you if you have a clinical negligence case.

If you want to do this, you have a 3 year time limit to make a clinical negligence claim. Action Against Medical Accidents (AVMA) offer impartial advice about clinical negligence and can help you find a solicitor. Their details are in Useful Contacts section at the bottom of this page.

You can find out more about ‘Clinical Negligence’ by clicking here.

Can i still make a formal complaint?

You may want to make a formal complaint to an organisation, such as the NHS or police, about your relative’s care or treatment before they died.

Sometimes, an inquest can give you information that helps with a complaint. This is why many families wait until after an inquest to complain.

If you do choose to wait until after the inquest to complain, remember the time limit for making an NHS complaint. You have 12 months from the event you are complaining about or from when you first became aware of the issue. The NHS can sometimes extend the time limit if there are good reasons.

If you think the inquest will take more than 12 months, contact your relative’s NHS Trust using their complaint procedure. You can do this before the inquest. Let them know that you are going to make a complaint, but you are waiting until the end of the inquest.

There is no time limit for making a complaint to the police, although you must try to do it as quickly as possible. The police can decide not to deal with a complaint if it is received more than 12 months after the incident. If you are complaining more than 12 months after the incident you should explain why your complaint has been delayed.

Any complaint about police conduct leading to a death must be investigated by the Police Complaints Commission.

You can find out more about:

  • Complaints by clicking here.
  • Complaints against the police by clicking here.

What are my rights at the inquest?

You, or your representative, can ask witnesses relevant questions. When asking questions, you must remember that the job of the inquest is to find out how your relative died. You must not ask questions that appear to blame someone for the death.

This is very important if there is a jury at your relative’s inquest. The jury can only come to a conclusion about your relative’s death based on the evidence that they hear during the inquest. If you tell them your beliefs or opinions about what happened the coroner may feel the jury cannot make a decision. This could lead to the inquest collapsing.

It can help you to think about the questions you want to ask before the inquest. You could send them to the coroner beforehand, so they have time to consider them. It is the coroner who decides whether a question is relevant to the inquest.

You may also want to get legal representation at the inquest who can take help you through the process. You can find more information on this further down this page.

What happens?

What will the inquest be like?

Facilities

Facilities are different around the country.

Some coroner’s courts have private waiting areas for friends and family. If the inquest will take some time the coroner may make a waiting room available for the family. Speak to your solicitor or the coroner’s office if you would like a waiting room to be available.

Other coroner’s courts will not have any separate areas at all, so you may have to wait in the same area as people who were involved in your relative’s death. This may be distressing. You can ask the coroner’s court about this before the inquest.

What to wear

Wear clothes that you are comfortable in. The coroner and legal representatives may be wearing formal gowns and possibly wigs. Witnesses may be dressed smartly or possibly in uniform. For example, if they are a paramedic or police officer.

Support

The Coroners’ Court Support Service (CCSS) are a registered charity who can give you practical and emotional support whilst you are at the coroner’s court.

They are not available in every court. There is more information in the Useful Contacts Section at the bottom of this page.

Who else will be at the inquest?

An inquest is a public hearing, so anyone can attend. You can bring someone as extra support. They don’t have to be a family member.

Some courts are quite small so you may find you are sitting near witnesses waiting to give their evidence. If you are worried about this, you can talk to your solicitor or the coroner’s office.

Will the press be at the inquest?

Members of the press can go to your relative’s inquest and can report on what has happened. Some families want the press to draw attention to their relative’s death. But some do not. You cannot stop the press from writing about the hearing. But they do have a code of practice and guidance to follow. And should be sensitive to grieving families.

If your relative’s inquest is high profile you may be asked for a statement by the press. You do not have to give a statement if you do not want to.

Can I take a break during the inquest?

You can ask the coroner’s court how long they expect the inquest to last. If it is more than a few hours you can ask if they will have breaks.

You can take a break whenever you would like to during your relative’s inquest, unless you are giving evidence at the time. You can come back into the room after you have had your break. Try to leave the room as quietly as you can.

If you need a break when you are giving evidence, you should let the coroner know.

Some coroners may warn families when distressing evidence is coming up to allow you to leave if you want.

What happens at the inquest?

The coroner will start the inquest. If there is a jury, the jurors will have to take an oath. The coroner will explain to the jury that they are not there to blame anyone for your relative’s death.

What happens if I have to give evidence?

The coroner and any legal representatives should treat all witnesses with respect, particularly people who have lost a loved one.

Usually, the coroner will ask family witnesses questions first. Witnesses will need to take an oath to promise to tell the truth. The coroner will usually ask questions first, guiding the witness through their statement. Once the coroner has finished asking the witness questions the coroner will ask if anyone else wants to ask a question.

Other people who can ask the witness questions are:

  • you or your legal representative,
  • other interested parties or their legal representatives, and
  • the jury.

Other interested parties might be the NHS Trust who cared for your relative.

What happens after all the witnesses have been questioned?

When all the witnesses have been questioned, the coroner sums up the evidence. You or your legal representatives do not have the right to do this. This makes asking the right witness questions important.

After summing up, the coroner or jury have to give their conclusion. This used to be called a verdict. It means saying how your relative died.

The coroner will explain the possible conclusions to a jury. The jury will leave to talk about the evidence privately to make their decision. It may take some time for the coroner or jury to reach their decision.

What conclusions could be made?

An inquest will end with a conclusion about how someone has died. Conclusions used to be called verdicts. You might see the term verdict, and this is the same as the conclusion. Some of the conclusions are:

  • accidental death or misadventure,
  • alcohol/drug related,
  • natural causes,
  • unlawful killing,
  • lawful killing,
  • suicide,
  • open, and
  • narrative.

An open conclusion is when the coroner or jury does not have enough evidence to say how your relative died.

A narrative conclusion is when a coroner or jury gives a longer explanation of what they feel are important issues. It can be a way of showing any problems or mistakes especially if there is an Article 2 inquest.

The coroner or jury no longer needs to have clear evidence to conclude that the death was the result of suicide. They can come to this conclusion if they feel it’s more probable than not that your relative intended to kill themselves.

You may feel that an organisation such as a prison or hospital neglected your relative and were responsible for their death. In rare cases the words “contributed to by neglect” can be added to the conclusion.

Neglect does not mean the same in law as it does in everyday language. So, there are not many situations when “contributed by neglect" can be added to the conclusion. It is rare for this conclusion to be given. This is a complicated area and you should discuss this with your solicitor. The verdict cannot say that any individual is guilty of neglect.

What if future deaths could be prevented?

Sometimes an inquest will show that something could be done to stop other deaths from happening. The coroner will write a report and tell the organisation, or person, that might be able to stop other deaths. For example, a hospital or psychiatric unit. This is called a ‘report to prevent future deaths’.

The organisation has to respond to the report within 56 days. They have to say What action they are going to take.

Representation

Can I get legal help for the inquest?

You usually have to pay for legal advice and representation. But legal aid can help people with low incomes pay for legal costs. The family of the person who died can get legal aid in the run up to the inquest. However, once the inquest starts legal aid is only given in exceptional circumstances:

  • if it is an Article 2 inquest, or
  • if there is a wider public interest in the person being represented at the inquest.

The legal aid rules are complicated, and it can be difficult to get funding for representation. If you do contact a solicitor, it is important to check that they have expertise in representing families at inquests. They will be more aware of the legal aid options available and will be able to advise you whether you are likely to be eligible for legal aid.

The charity INQUEST may be able to recommend a solicitor with the right expertise to help you. Their contact details are in the useful Contacts section at the bottom of this page.

If you get a solicitor, they can:

  • talk to the coroner,
  • get a copy of your relative’s medical records,
  • advise you about the how the inquest works,
  • tell you if they think an expert report would help, or
  • represent you at the inquest itself.

At the inquest, the solicitor may instruct a barrister to represent you and question the witnesses. A barrister is a type of lawyer who works at higher levels of court. You would usually meet the barrister before the inquest.

Conclusions, appeals & complaints

What happens after the inquest?

Final death certificate

After the inquest, the coroner will allow the death to be registered and issue the final death certificate. The coroner’s officer will explain how to get a copy of the death certificate. You have to pay a small fee for it. They will also send a burial order, a cremation certificate or permission to send the body abroad if this hasn’t already been done.

Clinical negligence

If you want to take legal action against a healthcare service, you need specialist legal advice. There is more information about this in the previous sections.

Formal complaint

You can make a formal complaint against the organisation in question. There is more information about this further down this page and also in the previous section.

Care Quality Commission

If you have concerns about the standard of care your relative received in hospital, you could contact the Care Quality Commission (CQC). The CQC check that hospitals meet national standards. It also checks that professionals are using the Mental Health Act properly.

You can share your experiences about hospital services on the Care Quality Commission website. The CQC will not investigate individual complaints. The CQC details are in the Useful Contacts section below.

Contacting a local Member of Parliament

You could contact the Member of Parliament (MP) for the area where your relative was getting mental health care. Some families have found MPs to be supportive and helpful when they have raised concerns about local or national mental health care issues.

Can I challenge a coroner’s decision?

You can challenge a coroner’s decision or inquest conclusion. If you are thinking about doing this, speak to a specialist solicitor.

The only way you can challenge a coroner’s conclusion is:

  • apply to the High Court for a judicial review, or
  • through the Attorney General to the High Court

Judicial reviews

If you want to apply for a judicial review this needs to be done as soon as possible. It has to be done within 3 months of the end of the investigation. You can challenge the decision through a judicial review if you think that the way the coroner investigated your relative’s death was not right.

The Attorney General

You can ask the Attorney General to apply to the High Court for another investigation to be held if this is in the interests of justice. For example, if new evidence has come to light. There is no time limit for these applications.

Can I make a complaint about the coroner?

You can make a complaint if you are not happy with the way a coroner has behaved. Or if you are not happy with the service provided by the coroner’s service.

Making a complaint about a coroner’s behaviour

If you are not happy about a coroner’s personal conduct, you can write to the coroner.

Some examples of behaviour that you can complain about are:

  • rudeness,
  • use of insulting, racist or sexist language,
  • unreasonable delays in holding the inquest, and
  • unreasonable delays in replying to your letters or phone calls.

If you aren’t happy with the coroner’s response you have a right to complain to the Judicial Conduct Investigations Office (JCIO). If you don’t want to complain directly to the coroner, you can also make the complaint to the JCIO. Their contact details are in the useful Contacts section below.

Making a complaint about the coroner’s service.

You can complain about the way a coroner or their staff handled the investigation into your relative’s death.

You can write to the coroner. You can also send a copy of your letter to the local authority which funds the coroner service. The coroner’s office will be able to tell you which local authority to contact.

If you are unhappy with the local authority’s response, you have a right to complain to the Local Government Ombudsman about how the local authority dealt with you. But the Local Government Ombudsman cannot review or alter a coroner’s decision.

The details of the Local Government Ombudsman can be found in the Useful Contacts section below.

Further reading

The Ministry of Justice: A guide to coroner services for bereaved people
This is an easy to read guide which takes you through the inquest process.

Website: www.gov.uk/government/publications/guide-to-coroner-services-and-coroner-investigations-a-short-guide

INQUEST handbook
A handbook created by the charity INQUEST who support bereaved people following a state related death. For example, if your loved one died whilst in police custody or in hospital.

Website: www.inquest.org.uk/useful-resources

INQUEST Skills and Support Toolkit
Families have helped the charity to produce an interactive resource. It aims to build a range of skills, from organising information relating to the inquest, speaking in public, to handling media attention.

Website: www.inquest.org.uk/useful-resources

Useful contacts

INQUEST
A charity that provides advice and casework for bereaved people following a state related death. For example, if your loved one died whilst in police custody or in hospital. They can also put you in touch with families who have been through similar experiences.

Telephone: 020 7263 1111
Address: 3rd Floor, 89-93 Fonthill Road, London, N4 3JH
Website: www.inquest.org.uk

Care Quality Commission
Monitors care in hospital and also monitors the use of the Mental Health Act.

Telephone: 03000 616161 (Monday to Friday, 8.30am to 5.30pm)
Email: enquiries@cyc.org.uk
Website: www.cqc.org.uk

Judicial Conduct Investigations Office (JCIO)
Can take on complaints about the behaviour, language or conduct of a coroner.

Address: 81 – 82 Queens Building, Royal Courts of Justice, Strand, London, WC2A 2LL
Website: www.judicialconduct.judiciary.gov.uk/

Action against Medical Accidents (AvMA)
Gives free, confidential advice and support to people affected by medical accidents, via a helpline and casework service.

Telephone: 0845 123 2352 (Monday to Friday, 10am – 3:30pm)
Address: Freedman House, Christopher Wren Yard, 117 High Street, Croydon, CR0 1QG
Website: www.avma.org.uk

Coroners’ Court Support Service (CCSS)
A registered charity whose volunteers give emotional and practical support to families and other witnesses attending inquests in certain parts of the country.

Telephone: 0300 111 2141 (Monday to Friday, 9am – 7pm, Saturday 9am – 2pm)
Address: Victoria Charity Centre, 11 Belgrave Road, London, SW1V 1RB
Email: helpline@ccss.org.uk
Website: www.coronerscourtssupportservice.org.uk

Cruse Bereavement Care
Offers free, confidential help to bereaved people. Also provides counselling and support groups at local branches. You can find your local branch on their website.

Telephone: 0808 808 1677 (9.30am-5pm, Monday-Friday – excludes bank holidays, with extended hours until 8pm Tuesdays, Wednesdays and Thursdays. Weekends 10am – 2pm)
Address: Unit0.1, One Victoria Villas, Richmond, TW9 2GW
Email: helpline@cruse.org.uk
Online chat via website: www.cruse.org.uk/get-help/crusechat (Monday - Friday, 9am – 9pm)
Website: www.cruse.org.uk

Compassionate Friends
Support for bereaved parents, siblings and grandparents.

Telephone: 0345 123 2304 (Open every day, 10am to 4pm, 7pm to 10pm)
Email: helpline@tcf.org.uk
Website: www.tcf.org.uk

The Local Government Ombudsman (LGO)
The final stage for complaints about a coroner’s service and local authority.

Telephone: 0300 061 0614 (Monday – Friday, 10am – 4pm)
Email: you can fill in a complaint form through the website
Website: www.lgo.org.uk

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