In such circumstances, the death is referred to a coroner to be investigated. This referral triggers a formal process in law in which the death is examined in great detail with the use of evidence. The case is then heard at a formal court hearing, known as an ‘inquest’, where the coroner reaches a conclusion, based on the evidence, as to the cause of death and what contributed to it.
This blog aims to explain the role of a coroner and the purpose of an inquest together with the steps to be expected where a coroner investigates an incidence of death. Please note that this information does not take into consideration deaths in custody or deaths whilst under a psychiatric hold.
Role of the Coroner
Whilst coronial inquests are themselves a branch of the legal system, they are unique in terms of their function and purpose in that they are subject to their own laws, rules and procedures. One such distinction being that a coroner’s role is not to find fault but solely to establish a factual outcome based on the evidence.
This is a concept known as ‘scope’ i.e. the scope of the inquest. The scope is limited to the coroner establishing the cause of death and any contributions to it. The coroner will determine what evidence falls within the scope of the inquest in order to be able to come to such a conclusion.
The key point to note here therefore is that the coroner’s role is not to establish or assign blame or fault, and indeed they are restricted from doing so: it is paramount that any death subject to inquest proceedings is treated with integrity and any conclusion reached done so by considering established facts and is not distracted by assertions of blame.
Before the Inquest
Once the death has been referred to the coroner, the coroner is then responsible for collating evidence and time tabling the relevant hearings. The steps are set out within various statutory powers.
Evidence
What is considered to be evidence in an inquest will differ from case to case and can include medical records, discharge summaries from a hospital, witness statements of medical staff or 999 calls. The coroner will be made aware upon referral of the death, the circumstances of the death, and this will often indicate as to what evidence is appropriate. The coroner will request and collate this evidence.
The family of the deceased are not required to provide any evidence, although for obvious reasons many choose to submit documents and evidence in which they believe to be relevant.
Once the coroner has received all of the evidence it will be reviewed by them coroner to determine which evidence they believe speaks to the immediate facts surrounding the death and falls within the scope of the inquest, and to extract any evidence that which does not. This is then distributed ahead of the inquest both to the family and any other personally interested persons (PIPs). PIPs are those connected to the deceased or involved in their death, e.g the family of the deceased and a Hospital Trust. The family do have the opportunity to contest the inclusion/exclusion of particular evidence if they wish, although the final decision remains with the coroner.
At this stage, the coroner will also determine whether any of the documentary evidence is materially in dispute. Where this applies, the coroner will summon the author or creator of the document to appear at the inquest in order to answer questions. Any evidence not in dispute will simply be read aloud and admitted to the court record during proceedings but it’s producer need not attend. This information is also circulated ahead of the hearing.
Pre-Trial Inquest Review (PTIR)
This is one of the very early stages in the process, and generally happens whilst the coroner awaits receipt of the evidence.
It is an administrative hearing and does not explore the circumstances of the death. It serves solely to admit the case to the court record and agree the scope and purpose of the inquest with reference to any particular facts or issues that are in dispute or are unclear.
The PTIR will be opened, and the key information admitted to the court record e.g. the name of the deceased and the place and date of death. The family do not need to attend the PTIR but they are permitted to should they wish. The hearing will then be concluded with the formal inquest to follow at a later date.
The Inquest Hearing
As detailed above, the coroner’s role is not to establish liability or assign blame. The purpose of the hearing is to explore the evidence at hand in order that the coroner can reach a conclusion regarding the circumstances of the death within the parameters of the scope that has been set.
In view of the restrictions limiting the coroner’s role to fact finding, this is reflected in the way that the coroner and indeed anyone advocating throughout the hearing is able to put questions to the witnesses. It is not a circumstance of cross-examination or an opportunity to aggressively question the witness. The coroner will have established the questions they wish to put to the witnesses ahead of the hearing and will be the first person to do so within the proceedings, following which parties are then offered the opportunity to ask their own questions.
In view of the restrictive questioning permitted within coronial proceedings, this can understandably lead to confusion and disappointment for families of the deceased who are unaware of these restrictions. They may wish to ask questions and attempt to do so, but may be curtailed by the coroner if the questioning is inappropriate or goes beyond the permitted scope. Families are often left feeling they are left without answers without a clear understanding of why.
Conclusion
Once the coroner has reviewed the evidence and the questioning of the witnesses has concluded, they can form their conclusion. The coroner will determine whether the proposed cause of death is accurate and, if so (or, if not), what it should be. This is then entered on to the deceased’s death certificate which will be prepared and given to the family. The family can then formally register the death.
The coroner can also provide commentary in relation the death, for example that the death was premature or that the deceased would not have died when they did had they received a particular medical treatment. This is known as a narrative verdict and appears on the death certificate. However, a narrative verdict is not always applicable and is a matter for the coroner to determine, based on the evidence, whether a narrative verdict is appropriate.
The coroner also has the power to prepare a Prevention of Future Deaths report (PFDR). The preparation of a PFDR is not mandatory in every case, however where a coroner identifies that there have been significant failings in the lead up to the deceased’s death, a PFDR can be prepared. The report in which the coroner outlines the failings and makes recommendations as to how they can be prevented in the future. The report is then sent to the relevant entity (i.e Hospital Trust) who must respond within 56 days. Again, this does not happen at every inquest, but is a further power given to coroners by the law in order to identify failures and prevent future deaths.
A PFDR is a public document and can be accessed online.
How Can We Help?
As outlined above, coronial proceedings are not straightforward and can be daunting for families of the deceased, particularly when these proceedings very often overlap grief. It can be an additional layer of trauma and upset, particularly where families feel they have not had the opportunity to really explore why and how they lost their loved one and have not been guided through the process.
Our inquest solicitors have established experience in representing and advocating for families in such coronial proceedings. Our representation is not limited solely to the proceedings itself but also in providing support to families: coaching them throughout the process, explaining what to expect and ensuring their questions are answered so far as they can be within the scope. We tackle the legal jargon and complexities for you so that you can focus on supporting each other.
If you are facing coronial proceedings following the loss of a loved one, Rothera Bray can help – please call us on 03456 465 465
