Inquests - At the inquest
This section looks at:
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.
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 here.
What will the inquest be like?
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).
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 here.
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?
- 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.
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.
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,
- road traffic collision,
- alcohol/drug related,
- open, and
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.38 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.
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