Cornoners Inquest Guide

Table of Contents


A coroner’s inquest can be very intimidating, especially for families who have no experience of the legal system.

In this blog, I give a brief introduction as to what to expect at an inquest,  to give families an overview about the purpose and process of a coroner’s inquest.


An inquest is an investigation into a death which appears to be due to unknown, violent or unnatural causes. The purpose is to find out who the deceased was, and where, when and how they died.

A coroner is obliged to investigate deaths which are not obviously “natural”. Deaths occurring as a consequence of accident, suicide, during or shortly after medical treatment will usually be investigated.

An inquest can be a daunting prospect for a grieving family, but also an important part of the bereavement process. Findings at an inquest can be relevant to compensation claims.

Coroners are responsible for making enquiries where the cause is unknown. The investigations are conducted on their behalf by a Coroner’s Officer.

It is different to other courts because there are no formal allegations or accusations and no power to blame anyone directly for the death. At the end of the inquest, the coroner will give his/her conclusion and this will appear on the final death certificate.

The death can then be officially registered. The conclusion cannot (in most circumstances) include any suggestion of blame.

 The inquest process, step by step

 If a reportable death occurs, it should be referred to the coroner by a doctor or the police. A family member can also invite the coroner to open an inquest.

  • The coroner considers information and decides whether an inquest is required. The coroner can either:
    • request more information (and open a preliminary “Investigation”); or
    • decide there and then that an inquest is required. The inquest is “Opened and Adjourned for further investigations”.
  • If the investigation or inquest is opened, usually a post-mortem examination (also called an autopsy) is performed to establish the probable medical cause of death. If the post-mortem shows an inquest is not necessary after all, the family are informed, and the process concludes. For example, if the post mortem determines the person died of natural causes. (After Post-Mortem, the family can usually then make funeral arrangements)
  • If an inquest is necessary, the coroner reviews and decides:
    • If a referral to the police/CPS is needed for possible criminal prosecution.
    • If no criminal issues, fixes a timetable for any evidence needed to be gathered.
    • If needed, arranges a pre-inquest review (all interested persons, including family, are invited) to discuss relevant issues, review evidence, identify witnesses or expert evidence required and agree a timetable for their evidence to be taken.
  • When investigations are complete, the inquest date is fixed, and witnesses are notified to attend to give evidence and answer questions.
  • The inquest hearing takes place in public. After hearing the evidence, the coroner gives a conclusion.
  • The coroner will complete the necessary paperwork and the death can then be registered.
  • If the issues are more complex, some steps may be repeated (e.g. pre-inquest hearings) or take longer.

There is more information about what happens after an inquest later in this guide, and on our dedicated inquest page.


A coroner will usually arrange a post-mortem to try and find out the medical cause of death. It is very rare for an inquest to go ahead if this has not taken place. You will be informed about this.

A family cannot usually object – this is a coroner’s legal obligation. Some post-mortems can be done noninvasively, such as by MRI scanning,  but this is still very rare. You can instruct a doctor to attend to represent you at the post-mortem – but this is also quite rare, and you will have to pay any fees incurred.

A body cannot be released to a family until the coroner gives permission. He/she will try to release the body quickly, but this is not always possible.

Body tissue taken for analysis at post-mortem can be reunited with the body later or disposed of in a suitably respectful way – you will be asked to decide on this.


If an inquest is to take place, it can be months (or even years) before the final hearing, depending on the complexity of the legal and medical issues. Most coroners aim to complete inquests within 6-9 months of the initial report of the death.

In the meantime: –

– The coroner can issue a Certificate of Fact of Death, which can be used to notify asset holders – this is often referred to as the ‘interim death certificate’.

– The funeral can be arranged as soon as the coroner confirms the post-mortem is complete.

– A Grant of Probate can be obtained.

– The death cannot be finally registered until after the inquest has been completed.


The inquest will take place in a court room. Some are traditional wooden panelled rooms, and some are more like modern office spaces. Various ‘interested parties’ are likely to be there, such as a hospital representative or insurer.

Each witness is likely to have submitted a statement to the coroner. That statement may be read out instead of a witness attending (this will be decided at any pre-inquest hearing).

The coroner will call each witness in turn and, if they are there in person, will ask them questions. The coroner will then ask each interested party whether they have any additional questions.

When the coroner has heard from all of the witnesses and any additional experts, they will give a conclusion.

Coroner's Courts Support Service Logo


As a family, an inquest can be an intimidating process. The coroner will try and help a family as much as possible, but it can be very difficult to make sure that all the right questions are asked. It can be a very emotional time for a family.

The coroner asks questions first of each witness. After that, any interested person such as a family member (or their lawyers) can ask more questions – but the questions must be relevant to the inquest and its scope, not, for example, about blame.

In some courts the Coroner’s Court Support Service operate to help families with practical arrangements on the day of the inquest, but they are unable to give legal advice.


Legal Aid is very rarely available, so you may have to pay for a lawyer. If you want legal representation, some will help you for free but won’t be able to do that for everyone. You may have legal expenses insurance (for example attached to household policies) or union membership which may help with legal fees.

If there may be a negligence claim relating to the death (road traffic accident, mistake in hospital, etc.), or if some issue of human rights may be involved, then see a specialist lawyer. In such cases, often the lawyer will represent you at the inquest as part of the negligence claim.

If the lawyer says he/she will charge you, make sure you know how much.

Inquests can involve very specialist legal issues, so always instruct a specialist lawyer. Ask if the lawyer is a member of one of the Accredited Specialist Panels (AvMA, Law Society, APIL), and if they have experience of inquests and coronial law.


At the end of the inquest, the coroner can give the following conclusions about the death:

  • Natural causes
  • Accident or misadventure
  • Suicide
  • Narrative, which enables the coroner to describe briefly the circumstances by which the death came about
  • Unlawful killing (or lawful killing)
  • Alcohol or drug related
  • Industrial disease
  • Road traffic collision
  • Neglect (usually contributing to another conclusion e.g. natural causes)
  • Open, meaning that there is insufficient evidence to decide how the death came about

Each of these has a specific legal meaning and is not always what might be understood e.g. neglect does not necessarily mean negligence.


After investigating the circumstances of a death, the Coroner will reach a conclusion on what caused the death, and why. The options they can reach are limited to an Official list of Conclusions. You can find out more about the Inquest process in our dedicated inquest guide, but what do the different conclusions mean, and when might they be used?



Whilst Accident and Misadventure are treated the same for statistical purposes they historically have slightly different meanings.  Misadventure is where someone doing something lawful unintentionally kills another.   The difference can be explained as accident reflecting death following an event over which there is no human control where as misadventure is an intended act but with unintended consequence.  In a medical context misadventure could reflect intended treatment with an unintended consequence.


An alcohol or drug related death covers both a death from the poisoning effect of being an addict and an accidental death resulting from abuse of alcohol or drugs.


More easy to understand, a conclusion of death by reason of Industrial Disease is used when the Coroner is satisfied that the death resulted from a disease caused by work.


Lawful and unlawful killing will rarely arise in a medical context.   Lawful killing is a deliberate act but justifiable such as self-defence.  Unlawful killing is closely dies in with criminal proceedings which will take place before any inquest.  Unlawful killing is the correct conclusion in cases of murder, manslaughter and infanticide.


This conclusion reflects the normal disease process and will be appropriate where someone dies as a result of disease naturally acquired.  A Natural Causes conclusion will not apply where there the disease was caused by work (Industrial Disease).  In a medical context a person who is suffering from a potentially fatal disease and where medical intervention fails to prevent the death will die from natural causes (as separate from possible misadventure).   Natural causes does not absolve a doctor of fault just as misadventure does not imply fault.  See more about Natural Causes here.


An open conclusion will be given if there is insufficient evidence to record any other suggested conclusion or where there is other evidence but the required standard of proof is not reached.  It is a conclusion of last resort.


This is a relatively new conclusion and applies in any circumstances where someone dies as a result of an incident on the road and involves a vehicle.


Currently an inquest may be opened to ascertain whether a child was born alive or not.  If the conclusion of the evidence is that the child was stillborn this will be the correct conclusion and no further investigation need be carried out.  This is an area of law which is currently under review.

See more about stillbirth here.


This conclusion means self-murder.  Taking your own life.  Suicide must never be presumed and must be based upon some evidence that the deceased intended to take their own life.


In place of the short form conclusions listed above the Coroner can give a narrative conclusion.  This is a brief explanation of the facts explaining how the deceased came by their death.  This can include a reference to neglect.


This does not equate to Negligence. Neglect is limited in a medical context to cases where there has been a gross failure to provide basic medical attention to someone obviously in need of it, and where that gross failure has played a part in the death.  See a more detailed piece on this a narrative including neglect here.

I act as an inquest advocate as part of Enable Law’s Inquest team. If you have been affected by a bereavement where there will be an Inquest find out more about our service, or contact us.


  1. Try to appoint one family member or family friend to be a spokesperson for the family. Try to agree who this should be – divisions within the family can be distracting.
  2. Write to the coroner in advance of the inquest setting out your main concerns. Try to be objective. Doing this will help the coroner make sure he/she addresses all the important issues from the family’s perspective and it helps you work out in advance exactly what those issues are.
  3. Ask the coroner, well in advance of the inquest, to disclose relevant documents to you. The coroner does not always have to do this, as some documents can be very upsetting. If you have a lawyer representing you, disclosure will usually be made to the lawyer.
  4. Keep in touch with the coroner’s officer, who will be your main contact and should give you all the practical help that you need (you will rarely get to see or speak to the coroner).
  5. The inquest can be extremely upsetting and emotionally charged, but for some people, it can be very helpful as a way of getting answers and as an important part of the grieving process. Think about taking a friend for support before, during and after the inquest.
  6. If you are unsure how you address a coroner in court, simply refer to them as ‘Sir’ or ‘Madam’.
  7. Usually children under 18 are not allowed to be at the inquest hearing or give evidence. This varies, so check with the coroner’s officer.
  8. Press can be present at the inquest. You don’t have to talk to them afterwards if you don’t want to, but sometimes it may be just what you want. It is usually best to give yourself some time for reflection after the inquest and before talking to the press.



The meaning of the coroner verdict “natural causes” as a conclusion is also not always straightforward or what families may expect natural causes to mean; particularly where they have concerns regarding the medical treatment provided to their loved one.

There is no formal definition of natural causes, but it is generally seen as the normal progression of a natural illness which has led to death, with or without any significant intervention.

In contrast, a death due to unnatural causes is a death caused by something else – sometimes a positive act, or a failure to act (omission) (other than proper attempts to save the person’s life). Nevertheless, in a case where it is suggested that the medical treatment provided may have been substandard, these distinctions can easily become blurred.

For example, a patient attending hospital with chest pain is sent home despite an abnormal test result and dies some time later as a result of a cardiac arrest. In these circumstances, a death could be seen to have arisen from natural causes due to the normal progression of the patient’s heart condition but similarly, the death could be seen as unnatural if the failure to follow up the abnormal test result is significant and, if followed up, would have prevented the death.

The conclusion the Coroner reaches will very much depend on the evidence given at the inquest by the witnesses and any medical experts, as well as the Coroner’s view on the relevant law.

A conclusion of natural causes does not necessarily imply that there is no negligence or civil liability, and a conclusion of unnatural causes does not necessarily mean that there is negligence. In addition, what may look like a death due to natural causes initially, may end up after all the evidence has been heard, as “accidental death”, which may or may not involve negligence.


The law in this area can be complex – if you believe that a person’s death was someone’s fault (after an accident, or treatment which went wrong) then you should take specialist legal advice.

Each inquest is different, and practice and procedure vary between coroners in different parts of the country. Coroners are legally qualified (solicitors or barristers) and some are also medically qualified. They appoint assistant coroners to help them.

Enable Law have a team of lawyers who are specialists in inquest law and we regularly represent families at coroner’s inquests. We are always willing to discuss ways in which we can help.

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