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31 Jul 2019

Advice correct as of August 2019

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.

An inquest is a fact-finding exercise – it is not intended to be adversarial i.e. not involving opposition or disagreement.

There are no formal allegations or pleadings and no criminal or civil liability is determined.

When is an inquest necessary?

An inquest is a public enquiry, held in cases where the death was sudden, unexplained, or violent.

An inquest would not normally be held if a postmortem examination of the body could explain the cause of death.

You should record the details of referral to the coroner in the patient’s records.

What happens at an inquest?

An inquest is usually held in a courthouse; however, hotels or local halls may also be used. Unlike a court case, there is no prosecution and defence, although the witnesses may be represented by lawyers.

The family of the deceased are entitled to attend. They do not require legal representation, but if legal action is being taken as a result of the death, they may engage a solicitor to attend the inquest and take notes.

Jury inquests

A jury will usually be appointed if the inquest is regarding a murder, manslaughter or infanticide; a road traffic accident; a death that took place in prison; a death that was caused by an accident, poisoning or a disease requiring notification to a government department or inspector; or the death occurred in circumstances, which if they continued or recurred, would endanger the health or safety of a member(s) of the public.


Witnesses may be required to attend the inquest to give testimony on oath regarding the circumstances and cause of the death.

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 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. Namely, 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 criminal investigation into a possible crime, the inquest may be adjourned.

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.

Further guidance in relation to giving evidence can be found on the Medical Protection factsheet entitled Giving Evidence (referenced below).

Legal representation

Only those who are considered an “interested party” by the coroner are entitled to legal representation. Such status would be given if the coroner is of the view that your actions could have caused or contributed to the death.

Your hospital may arrange legal representation for you and also to protect the hospitals’ interests.

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 the hospital, representation may be provided through Medical Protection.

Please let Medical Protection know if you are asked to attend as an “interested party”.


When the proceedings have been completed, a verdict is returned in relation to the identity of the deceased, and how, when and where the death occurred. The range of verdicts open to the coroner (or jury, if one is present) include:

  • Accidental death
  • Misadventure
  • Suicide
  • Natural causes
  • Unlawful killing
  • Open verdict – 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 if it is appropriate. This may have implications for the healthcare professional involved.

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.

Recommendations from the coroner

A general recommendation designed to prevent similar deaths occurring may be made by the coroner or jury. All depositions, post mortem reports and verdict records are preserved by the coroner and are made available to the public.

Further information