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Inquests – what to expect

19 May 2021


Not all coronial inquiries become inquests, indeed most are resolved ‘on the papers’, meaning the coroner makes a finding after reading all the evidence in chambers.  If the coroner needs to hear from witnesses in person, they will hold an inquest in court. Often an inquest occurs as a consequence of request from family. A coronial inquest, which is held in public, is an inquisitorial rather than an adversarial process with the aim of establishing facts, rather than apportioning blame.

An inquest can take anything from less than one hour to a few weeks, depending on the complexity of the circumstances surrounding the death. Although the purpose of an inquest is not to determine liability for death, it can be a daunting, unfamiliar and stressful experience. There is also the potential for the coroner to make adverse comment about healthcare providers.


The inquest is held so the coroner can review all the evidence relating to the death of a person and discover what lessons can be learnt from it. The coroner will hear evidence from anyone who has information relating to the death.

The inquest also enables the coroner to make recommendations or comments on the avoidance of circumstances similar to those in which the death occurred, or to comment on how other people should act in such circumstances, so as to reduce the chances of other similar deaths occurring.


The inquest will not usually be held until all investigations into the death have been completed. This may be an investigation by the police, the pathologist or any other external investigation that the coroner has requested, or that an outside agency is undertaking.

Interested parties will be advised of the time, date and location of an inquest. A pre-hearing conference may be held with interested parties including the immediate family to determine particular issues to be resolved.

Families, witnesses and experts

Parties at an inquest may include the bereaved family and hospital or other service providers, as well as individual clinicians. All may have legal representation and be cross-examined on their evidence.

This can be an opportunity for a family and the coroner to seek answers to questions directly from the deceased’s healthcare providers, so it is important to be prepared for what can be a very challenging situation.

The coroner conducts the inquest, witnesses and experts may be called upon to give evidence, or witness statements may be read, and the pathologist’s report, papers and any other findings may be presented. The immediate family can, either personally or through legal counsel, question witnesses.

Giving evidence

It is usually possible to anticipate questions or issues that will arise during cross-examination. Thinking about these in advance of the inquest is advisable.

Medical Protection can instruct a barrister to represent members at an inquest and to assist in preparing the member to give evidence and be cross-examined. An inquest is a thorough process and can last for a period of time ranging from hours to weeks, depending on the issues and number of witnesses involved. However, a health professional witness would only be expected to attend for the day or two at which they give evidence. There is the potential if necessary for evidence to be presented by audio-visual link.

Closing an inquest

At the end of an inquest, after hearing all the evidence, a coroner may give either the final findings into the death, or may just announce interim findings. Interested parties, particularly if there is to be an adverse comment, are given an opportunity to respond to draft findings and recommendations. Once the inquiry is closed, the coroner will publish their recommendations. A copy of these will be made available to the family.

Medical Protection can advise and assist members asked to provide evidence and encourages members to call Medical Protection when information is first sought.

Further information