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.

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

***** 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?

If your relative dies, the doctor who treated them will issue a medical certificate. The doctor writes the cause of death on the certificate. From April 2018 the Department of Health are introducing a different process. The death certificate will be checked and co-signed by an independent medical examiner. This means that two doctors have to agree about the cause of death.

In some situations the doctor will have to tell a coroner about a death. The coroner will usually be in the area where your relative died. The doctor must tell the coroner if your relative’s death needs to be investigated. The coroner has to investigate if they suspect that:

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

State detention includes immigration detention centres and secure mental health hospitals.

Other people can also report a death to the coroner including:

  • the police,
  • a registrar of deaths, or
  • a family member.

The Chief Coroner can make a senior coroner investigate even if there is no body. This might be after someone has been cremated. The coroner will look at the information about your relative’s death. If they decide that their death was natural they can end the investigation. They will tell the registrar. You can then arrange the burial or cremation.

The coroner may decide that more information is needed to find out how your relative died. They will arrange for a post-mortem examination to be carried out. There is more information about this below.

After the post-mortem examination is finished, there might be an inquest. There is more information about this further down on this page.

What and who

What is a coroner?

The local authority employs a coroner to be responsible for a certain area. A coroner is an experienced and qualified legal professional. They may also have a medical background. There will be one senior coroner for each coroner area who will be assisted by one or more assistant coroners.

The coroner has an office, which is run by a coroner’s officer. Coroner’s officers help the coroner with:

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

Coroner officers cannot make any legal decisions.

You will have most contact with the coroner’s officer before your relative’s inquest. They make arrangements for the inquest. You might be in touch with them to pass information to the coroner. The coroner’s officer may pass information to you before the inquest.

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?

This section covers:

  • Do I have to agree to a post-mortem?
  • Can I go to the post-mortem?
  • Can I stop a post-mortem examination? Can I see the post-mortem report?
  • Can I ask for another post-mortem?

A post-mortem examination, or post-mortem, is a medical examination of a body to find out the cause of death. Sometimes it is called an autopsy. A post-mortem helps the coroner to decide if they need to hold an inquest. It will usually happen a day or two after your relative has died.

When a coroner arranges a 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 that your relative may have taken. This is called a toxicology report. It can take about 6-8 weeks for the report to be ready.

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 should 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. Some pathologists can use MRI scans to try and find out how someone died. This method is new and not always reliable. You may have to pay for these tests. Coroners will take your views into account before they ask for a post-mortem. But if the pathologist cannot tell how they died the law says they have to do a post-mortem.

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 medically qualified representative or lawyer could represent you. 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.

You might see marks on your relative’s body that look like bruises. This can happen during the examination.

Can I stop a post-mortem examination?

If you don’t think that the coroner needs to do a post-mortem then you should talk to them. If they still feel they need a post-mortem 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 see the post-mortem report?

If you are an ‘interested person‘ you can ask the coroner for a copy of the post-mortem report. You may have to pay a fee. The coroner can refuse to give you a copy of the report if they have good reasons. There is more information about interested persons further down this page.

It can take a while for the pathologist to finish the report for the coroner. It may take longer if they need to do extra tests. You may have to wait a few weeks.

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 need to ask the coroner if they will agree to a second post-mortem.

You will need to get a solicitor to help you find a pathologist. You need to make sure you get a pathologist who has specialist knowledge. You will have to pay for the pathologist. You will also have to arrange for your relative’s body to be properly preserved.

A second post-mortem may delay your relative’s funeral.

What is an inquest?

This section covers:

  • What does an inquest cover?
  • When should a coroner hold an inquest?
  • Can I ask questions at the inquest?
  • What is an “interested person”?
  • Will the inquest find out who is responsible for my relative’s death?
  • What should I do if I think there should be an inquest into my relative’s death?

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

The coroner will tell certain people when your relative’s inquest will take place. The coroner will announce if there is an inquest soon after your relative’s death. This will be short hearing to confirm your relative’s identity. The full inquest hearing will take place at a later date.

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.

If your relative died in a psychiatric unit, there should be an Article 2 inquest. This sort of inquest does look at wider questions. Article 2 inquests are discussed in more detail in the next section.

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).

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. An interested person can be:

  • a relative or partner,
  • 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.

The coroner will not have to contact all of the interested persons if they are all from one family. The coroner’s office will expect you to pick someone to be the main point of contact for the family. If your family is divided you can pick two.

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

An inquest is only 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. However, it cannot 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?

Article 2 of the European Convention on Human Rights is the right to life. This means that the state has a general duty to protect life. If someone dies when they are under the care or protection of the state then this has to be investigated.

The coroner may need to hold an Article 2 inquest if your relative died:

  • on an inpatient mental health ward,
  • detained in prison,
  • detained in an immigration centre, or
  • in police custody.

In a normal inquest the coroner will identify the immediate cause of death, or how the person died. In an Article 2 inquest the coroner has to investigate in much more detail. They will look more carefully at the circumstances in which your relative died. These inquests must be held with a jury.

If you think that Article 2 is relevant to your relative’s death but the coroner does not 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 end of the 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.

But an inquest will only consider:

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

If you have questions to ask witnesses you can ask them during the inquest once you’re registered as an interested person. There is more information below that tells you how to prepare for the inquest.

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?

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?

Usually the coroner where your relative died will do the investigation. Sometimes the investigation is done by a coroner in a different area. An example could be where someone was injured in a road traffic incident but was then moved to a hospital in a different area for specialised care and later died from their injuries. It may be appropriate to transfer the investigation to the area where the incident happened, especially if it is also near to where the deceased’s family live.

If an investigation is transferred to a coroner in a different area, the new coroner will tell you this has happened. They will also tell you the reasons why. The coroner’s office will ask you about this first if they can.

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.

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 the coroner releases your relative’s body, they will also issue a temporary death certificate. A death certificate is a record of who has died and the cause of death. The coroner needs a death certificate to release your relative’s body. And you need a death certificate to be able to hold a funeral. 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 give you a final death certificate. The final death certificate will have your relative’s cause of death on it. You need the final death certificate before you can register your relative’s death.

Is there a jury?

Will there be a jury at the inquest?

Most inquests are held without a jury. A jury inquest will take place if your relative died:

  • in custody or state detention, and,
    • the death was a violent or unnatural one, or
    • the cause of death is unknown.
  • because of a mistake by:
    • a police officer, or
    • a member of the services police force
  • because of an accident, poisoning or disease which should be reported to the authorities – such as accidents at work.

The jury will be between seven and eleven people.

Preparation & rights

How can I prepare for the inquest?

  • Health records
  • Pre-inquest reviews
  • Witnesses
  • Statement
  • Getting a copy of evidence before the inquest
  • Independent reports
  • Clinical Negligence
  • Formal complaint

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.

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.

Witnesses

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,
  • by video link, or
  • in writing.

If the witness gives evidence in writing they do not need to come along in person.

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 (perhaps because they are disabled),
  • there is good reason why the witness should not come (for instance where the person is abroad or ill),
  • 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 see the evidence and agree that the coroner can read it out. 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 decides id the written evidence should be read out.

Statement

You and your family can write a statement about your relative’s death. You could also include any concerns or questions that you would like to be answered. You can send this to the coroner before the hearing takes place. They do not have to use the information you send them.

Getting a copy of evidence before the inquest

The coroner will decide what written evidence to show you before the inquest. This includes witness statements and expert reports. You do not have a legal right to this information but the coroner should do what is fair. The coroner can refuse to give you a copy of the report but has to have good reasons for doing so. If the coroner agrees to show you the evidence then this will normally be an electronic copy.

If the coroner is holding an Article 2 inquest, then you have stronger grounds to ask for this written evidence before the inquest.

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.

The coroner can call experts to the inquest to give evidence in person.

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 three 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 end of this page.

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

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 complaints 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 has to 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.

What happens?

What will the inquest be like?

  • Facilities
  • Private waiting areas
  • What to wear
  • Support
  • Who else will be at the inquest?
  • Will the press be at the inquest?
  • Can I take a break during the inquest?

Facilities

Facilities are different around the country. Some courts may have vending machines to buy drinks but some do not. You can ring the coroner’s office and ask what sorts of facilities are available.

Private waiting areas

Some coroner’s courts have waiting rooms. 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 can show you the court before the inquest. At the inquest itself, they can come with you if you need to take a break. They are not available in every court. There is more information in the Useful Contacts Section at the end 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 ethics 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?

  • What will happen at the inquest?
  • Witnesses and evidence
  • Summing up
  • Conclusions
  • After the conclusion

What will happen 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.
  • The coroner will ask the jury to leave the room whenever the coroner and any interested persons need to discuss any legal details of the case. This is because the jury can only make a decision based on the evidence that they hear.

Witnesses and 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.

The coroner can read out any written witness statements of witnesses who are not at the inquest.

Summing up

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 decide on the conclusion. It may take some time for the coroner or jury to reach their conclusion.

Conclusions

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. There is no set list but some of the conclusions are:

  • natural causes,
  • self neglect or lack of care,
  • unlawful killing,
  • lawful killing,
  • accident or misadventure,
  • suicide,
  • road traffic collision,
  • alcohol/drug related,
  • open, and
  • narrative.

The coroner will ask the jury to have a conclusion they all agree with. However, if they have been trying to decide for a long time the coroner will accept a conclusion from the majority. This means that one or two people at the most do not agree.

If there is a conclusion of suicide or unlawful killing, the coroner or jury need to have clear evidence of this. For suicide this could be a suicide note. The coroner or jury have to be sure beyond all reasonable doubt. This is different to the other conclusions, where they just have to be sure on the balance of probabilities. On the balance of probabilities means they need to believe it was more likely than not. If someone did something that caused their death, but there is not enough evidence that they meant to die, then the coroner cannot give a conclusion of suicide.

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. But a coroner or jury cannot say anyone is responsible.

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.

The coroner will make a Record of an inquest. This includes:

  • the conclusion,
  • statutory determinations, and
  • statutory findings.

Statutory determinations are who died, how, when and where. Statutory findings are pieces of information needed by the Births and Deaths Registration Act 1953.

After the conclusion

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 coroner must make a report where:

  • their investigation shows that there could be more deaths in the future, and
  • things should be done to help stop deaths form happening.

The coroner may recommend that something should be done, but cannot say what that should be.

The organisation has to respond to the report within 56 days. They have to say when they will change things to stop more deaths form happening.

All reports have to be sent to the Chief Coroner for England and Wales. They can publish the whole report or a summary of it. They can send copies to anyone who may find it useful.

Representation

Can I get legal representation at 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, legal aid may be needed to carry out a full investigation into a death, 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. INQUEST may be able to recommend a solicitor with the right expertise to help you.

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 and appeals

What happens after the inquest?

  • Final death certificate
  • Copies of evidence
  • Clinical negligence
  • Formal complaint
  • Care Quality Commission
  • Contacting the local Member of Parliament

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.

Copies of evidence

An interested person can request copies of the post-mortem report, and documents that are relevant to the investigation. The coroner’s office can charge a fee if they give you documents after the inquest has finished. You can also go to the coroner’s office to look at a document. There is no charge for this service.

All inquests must be recorded and you can get a recording of the inquest on a disc or in other electronic form for a fee. You can also get a transcript although the fee for this will be higher than for an electronic copy.

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 section.

Formal complaint

You can make a formal complaint against the organisation in question. There is more information about this 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 look into individual complaints. The CQC details are in the Useful Contacts section.

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 appeal the verdict or 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 High Court does not have to order a new inquest.

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.

Useful contacts

INQUEST
A charity that gives lots of information about inquests including the rights
of the family to be involved. It runs an advice telephone and email service.
It has also produced ‘The inquest handbook’. INQUEST gives a free copy
to bereaved families or you can read it on their website.

Telephone: 020 7263 1111
Address: 3rd Floor, 89-93 Fonthill Road, London, N4 3JH
Email: Via website - www.inquest.org.uk/forms/help-and-advice-form
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)
Address: CQC National Customer Service Centre, Citygate, Gallowgate, Newcastle upon Tyne, NE1 4PA
Email: Via website - www.webdataforms.cqc.org.uk/Checkbox/contactus.aspx
Website: www.cqc.org.uk

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

Telephone: 0207 073 4719 (Monday – Friday, 9am – 5pm)
Address: 81 – 82 Queens Building, Royal Courts of Justice, Strand, London, WC2A 2LL
Email: inbox@jcio.gsi.gov.uk
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 – 5pm) or 0203 667 7884 to leave a message
Address: Victoria Charity Centre, 11 Belgrave Road, London, SW1V 1RB
Email: info@ccsupport.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)
Address: PO Box 800, Richmond, Surrey, TW9 1RG
Website: www.cruse.org.uk

Compassionate Friends
Support for bereaved parents, siblings and grandparents.

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

Further reading

You can find information on what to do after someone dies on the GOV.UK website:

Website: www.gov.uk/after-a-death/overview

The coroner’s office should give you a booklet about the coroner’s investigation process.

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