A Guide to a Coroner’s Inquest

If you or your family are facing a coroner’s inquest, you don’t have to navigate the process alone. At Tees, we understand how important it is for families to have a thorough investigation into their loved one’s death. Our experienced team is here to offer compassionate guidance, support, and legal representation.

What is a coroner’s inquest?

A coroner’s inquest is a formal investigation into a death. It is held in specific circumstances, including when:

• The cause of death is unknown.
• The death was violent or unnatural.
• The deceased was in custody, state detention, or detained under the Mental Health Act.
• The death occurred as a result of a medical procedure/treatment. 

Inquests are not designed to assign blame or responsibility but rather to determine the identity of the deceased, as well as when, where, and how they died.

What is an Article 2 inquest?

An Article 2 inquest is a more in-depth investigation held when the state may have failed to protect someone’s life. These inquests often involve deaths in custody, psychiatric hospitals, or other situations where the state played a role.

Prevention of future death reports

Following an inquest, a coroner can issue a Prevention of Future Death Report (PFD) if they identify risks that could lead to further deaths. These reports are sent to relevant organisations or individuals, recommending changes to prevent similar incidents.

Understanding the role of a coroner

A coroner is an independent judicial officer with legal qualifications and significant experience. Their role is to investigate sudden, unexplained, or unnatural deaths. Coroners can request post-mortems, gather evidence, and conduct inquests to establish the facts of a death.

Post-mortems: What to expect

A post-mortem, also known as an autopsy, is conducted by a pathologist to determine the cause of death. While the coroner decides if a post-mortem is necessary, they must consider the family’s views and any cultural or religious beliefs. Families can request a copy of the post-mortem report, though it may only be released after the inquest.

When will the inquest take place?

Inquests are typically held within 6-9 months of a death. During this period, the coroner will:

• Gather evidence, including medical records and witness statements.
• Contact the family to explain the process.
• Potentially hold a pre-inquest review to organise evidence and identify issues.
• Issue an interim death certificate to allow families to manage practical matters.

What happens during the inquest?

The inquest is a public hearing where evidence is presented to establish the facts of the death. Key participants include:

• Witnesses, including doctors, police officers, or medical experts.
• Family members, who may provide personal testimony.
• Legal representatives, especially in cases involving state bodies.

The coroner may also call for independent expert opinions to ensure a complete understanding of the circumstances.

Conclusion of the inquest

At the end of an inquest, the coroner or jury will deliver a conclusion that falls under one of several categories, including:

• Natural causes
• Suicide
• Accident or misadventure
• Unlawful or lawful killing
• Industrial disease
• Stillbirth

In some cases, a narrative conclusion is given, providing a detailed account of the circumstances surrounding the death.

Legal representation at an inquest

Having legal representation can be invaluable, particularly if there are concerns about the care a loved one received. Our experienced solicitors can help ensure that the right questions are asked, and all relevant evidence is considered.

State bodies are often represented by legal professionals, so having your own solicitor can help provide a balanced and thorough investigation.

Contact us for support

If you are facing a coroner’s inquest and would like to discuss your options, our dedicated team at Tees is here to help. Contact us for a no-obligation conversation about how we can support you through this challenging time.