An inquest is a fact-finding exercise that is conducted by the coroner and, in some cases, in front of a jury. The purpose of an inquest is to find out who died – when, where, how and in what circumstances. This factsheet gives further information about what happens at an inquest.
What is an inquest?
An inquest is an inquisitorial proceeding, to find out:
- Who the deceased was
- When and where the deceased died
- How and in what circumstances
This is a fact-finding exercise – which means it is not adversarial, and there are no formal allegations or pleadings.
When is an inquest necessary?
An inquest is held in cases where the death was:
- violent or unnatural
- when a person is in state detention, including prison/police custody, detention under the Mental Health Act
- or when the cause of death is still uncertain after a postmortem.
It is usual for the coroner to hold an inquest when a death occurs within 24 hours of admission to hospital or a surgical procedure, although this is not mandatory. If there is a possibility that a medical procedure contributed to or caused the death, it should be discussed with the coroner, regardless of the timescales involved.
You should record the details of referral to the coroner in the patient’s records. The coroner may also hold an inquest if the death was due to natural causes and an inquest is considered by the coroner to be in the public interest.
Giving evidence at an inquest
Evidence is given by witnesses under oath, which means that you are under a legal obligation to tell the truth at an inquest (see the MPS factsheet on Giving evidence). It is not a function of the coroner to apportion blame – the coroner’s court is one of investigation and inquiry; it is not adversarial.
However, questions from family members can be hostile and interested persons have the right to representation. Your trust may arrange legal representation to protect the trusts’ interests. They may also be able to represent you. If you are self-employed – for example, in general practice – or in cases where there is a potential conflict between your interests and those of your employing trust, separate representation can be provided through MPS.
Notifying the GMC and NHS England
The GMC publication Good Medical Practice has been modified and updated (the latest version came into effect on 22 April 2013) and there is now an obligation (set out at paragraph 75[a]) for a doctor to inform the GMC (without delay) in circumstances when they have been criticised by an official inquiry (which would include a coroner’s inquest).
A link to the relevant guidance can be found here.
A change to the National Health Service (Performers Lists) (England) Regulations 2013 places performers under an obligation to inform NHS England if the coroner has found that the performer’s actions have caused, or contributed to, the death of the deceased, or otherwise had their conduct brought into question at an inquest conducted as part of an investigation under the Coroners and Justice Act 2009.
If a doctor is concerned that they may be (or have been) criticised in the context of a coroner's inquest (including in a Regulation 28 report – see section headed "Prevention of future deaths") then they should contact MPS at the earliest opportunity to seek advice about the appropriate steps to take.
You must be honest and trustworthy when giving evidence. Make sure that any evidence you give or documents you write, or sign, are not false or misleading. You should recognise and work within the limits of your competence, and abide by this guidance even when giving evidence in non-medical scenarios.
Two key points:
- You must take reasonable steps to check the information
- You must not deliberately leave out relevant information.
A jury will usually be appointed if the inquest is regarding a death whilst under state detention (including detention under the Mental Health Act), an industrial accident or poisoning, or as a result of injury by a police officer. It will also be appropriate where deaths occurred in circumstances that, if repeated, could prove prejudicial to public safety (for example, train crashes).
The coroner can bring the following verdicts:
- Natural causes
- Accident or misadventure
- Narrative, which enables the coroner to set out the circumstances by which the death came about
- Unlawful killing
- Miscellaneous (drug dependence/industrial)
- Open, meaning that there is insufficient evidence to decide how the death came about – the case is left open in case further evidence appears.
The coroner does not decide issues of clinical negligence; however, the phrase “aggravated by self-neglect or lack of care” can be added to the first four verdicts if it is appropriate. This may have implications for the healthcare professional involved. The coroner’s verdict can only be challenged by judicial review in the High Court, but this must be within three months of the conclusion of the inquest.
The coroner can refer a doctor or doctors to their regulatory body if the coroner considers that it would prevent a recurrence of the incident that caused the death.
Standard of proof required at an inquest
The standard of proof applied at an inquest is the civil standard – the coroner and jury must be sure that it was more likely than not (on the balance of probabilities) that the facts have been found proven to support the verdict. There are exceptions: if the verdict of suicide or unlawful killing is reached, it must be proven beyond all reasonable doubt (this is the criminal standard).
What happens at an inquest?
An inquest is held in public and is a formal proceeding. Unlike a court case, there is no prosecution and defence. However, the witnesses may be represented by lawyers.
The coroner decides who to call as a witness. As part of his investigation, the coroner will request a statement from you and may call you as a witness at the inquest. If you are called as a witness, the coroner may ask you to read through your statement, or may take you through the statement in court. You may be asked to produce a report and may not be called as a witness if your evidence is unlikely to be controversial.
“Interested persons” are permitted to ask questions. The coroner will decide who fulfils this criteria. The questions will not be in the nature of a cross-examination, as in other courts. You are not obliged to answer the questions if the answer would incriminate you. If the coroner is not satisfied that all the information is available at the inquest, or the appropriate witnesses are not available at the inquest or there is to be a police investigation into a possible crime, the inquest may be adjourned.
Prevention of future deaths
Following the inquest, the coroner can write a report in cases where the evidence suggests that further avoidable deaths could occur and that, in the coroner’s opinion, preventative action should be taken. The report will be sent to the person or authority who may have the power to take the appropriate steps to reduce the risk, and they have a mandatory duty to reply within 56 days. These reports, formerly known as Rule 43, are now routinely published on www.judiciary.gov.uk. This means that, for the first time, the public will have access to these reports in a searchable and readable format.