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What does a Coroner do? What is the Inquest process?

Losing a loved one is a deeply painful experience, and when the circumstances surrounding their death are unexpected or unclear, it can be even more challenging. If this is the case, you may encounter a legal process called an inquest.

What is an Inquest?

An inquest is a formal inquiry led by a coroner, an official appointed to investigate deaths that appear unnatural, unexpected, or violent. The Coroner is required to investigate a death where there is a suspicion of industrial disease. Often, the family will need to ask the GP to make an online referral to the Coroner.

The coroner's primary objective is to answer four key questions:

  1. Who: The coroner needs to identify the deceased person definitively.
  2. When and Where: Establishing the exact date and location of death is crucial.
  3. How: Determining the cause of death is the central focus of the inquest. This may involve a post-mortem examination, also known as an autopsy.
  4. Other Contributing Factors (Optional): In some cases, the coroner may investigate broader circumstances surrounding the death, such as potential safety hazards or systemic issues that may have contributed to it.

The purpose of an Inquest

It's important to understand that an inquest is not a criminal trial. Its purpose is not to assign blame or determine criminal liability. The coroner is not a judge and there are no prosecutions or defences presented. The focus is purely on gathering facts to create a clear picture of how and why the death occurred.

The coroner will make it clear that the inquest is not an opportunity to place blame on any individual or organization. However, if evidence suggests potential medical negligence or other issues, this may be explored further through separate legal avenues after the inquest concludes.

The investigation process

The coroner has the authority to gather a wide range of evidence to answer the key questions. This may include:

  • Medical records: Including any relevant medical history and treatment information of the deceased.
  • Police reports: Providing details of the scene and any ongoing investigations related to the death.
  • Autopsy report: Containing the findings from the post-mortem examination, which helps establish the cause of death.
  • Witness statements: From anyone who may have information about the deceased or the circumstances surrounding their death. This could include family members, friends, medical professionals, emergency responders, or anyone with relevant details.
  • Family statements: The coroner may request a statement from the family about the deceased's medical history, lifestyle, and any other relevant information.

The coroner may also hold a Pre-Inquest Review (PIR) hearing. This is a preliminary meeting to discuss the evidence needed, identify potential witnesses, and establish the overall scope of the inquest. Once all necessary evidence is gathered, the inquest will be scheduled for a formal hearing.

Inquests are typically held in open court, meaning that the public and the press are generally allowed to attend. This includes the family of the deceased, who will be invited and given a designated area to sit. The coroner may also ask anyone they consider an "interested party" to attend. This could include medical professionals involved in the deceased's care, representatives from relevant organizations, or anyone with a legitimate stake in the inquest's outcome.

During the inquest, the coroner will question the witnesses and consider all presented evidence. The family and any other interested parties may also be given the opportunity to ask questions to assist the coroner in understanding the circumstances surrounding the death.

At the end of the inquest

After reviewing all the evidence and witness testimonies, the coroner delivers a formal conclusion that addresses the four key questions. This conclusion will be a public record and may be crucial for obtaining a final death certificate.

In some cases, if the coroner believes there is a significant risk of similar future deaths occurring under similar circumstances, they may issue a "Prevention of Future Deaths" report. This report contains recommendations for preventing such tragedies and is typically sent to relevant authorities or organizations who can take action to address identified risks.

Closure for the family

Following the inquest, the family will receive a final death certificate. While this doesn't erase the pain of their loss, it can be a helpful step towards moving forward with the legal and emotional aspects of their grief. The inquest process can provide some answers and a sense of closure, although it's important to remember that grieving is a personal journey that takes time.