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There are two legal routes and two complaint routes. Under section 13 of the Coroners Act 1988, the High Court can order a fresh investigation — but only on an application by or under the authority of the Attorney General, so you must first ask the Attorney General for that authority. Judicial review is a different thing with a different test: a High Court challenge to the lawfulness of a coroner's decision or the conduct of an inquest, which must be brought promptly and in any event within 3 months. Separately, you can complain about how the investigation was handled, or to the Judicial Conduct Investigations Office about a coroner's personal conduct — neither of which can change a conclusion.
If you believe a coroner has made an incorrect decision, reached the wrong conclusion, or conducted an inquest unfairly, you have legal options to challenge. However, challenges are difficult, expensive, and rarely successful. Understanding the grounds for challenge and the processes involved is essential before proceeding.
This page sets out what the routes are and what each one requires. It is not legal advice, and it does not tell you which route to take — that depends on facts we cannot see.
On numbers:
No official statistics are published on how many section 13 applications or judicial reviews of coroners are made, how many succeed, how long they take, or what they cost. Earlier versions of this page carried figures for all four. They were not drawn from any source and have been removed.
When: After an inquest has concluded with a conclusion you believe is wrong or insufficient.
Process: Section 13 of the Coroners Act 1988 applies where the High Court is satisfied, "on an application by or under the authority of the Attorney-General", that the grounds are made out. So the first step is asking the Attorney General for authority — the fiat — to bring the application.
What the court can do: order an investigation under Part 1 of the Coroners and Justice Act 2009, by the same coroner or another in the same area; quash any determination or finding made at the earlier inquest; and order the coroner to pay such costs of the application as the court thinks just.
Deadline: section 13 sets none. That is one of the practical differences from judicial review, which has a three-month longstop.
When: to challenge the lawfulness of a decision by the coroner — before, during or after an inquest. That can include a decision on the scope of the inquest, a refusal to hold one at all, procedural unfairness, or a conclusion no reasonable coroner could have reached.
Process: a claim in the Administrative Court, which first needs permission from a judge before it goes to a full hearing.
Deadline: CPR 54.5 requires the claim form to be filed promptly, and in any event not later than 3 months after the grounds to make the claim first arose.
When: For concerns about how the investigation was conducted, delays, or coroner behavior.
Process: Write to the Chief Coroner outlining your concerns.
Outcome: Can result in guidance to the coroner, but won't overturn conclusions or order new inquest.
When: For serious complaints about the coroner's personal conduct.
Process: Submit formal complaint to JCIO.
Outcome: Can result in disciplinary action against the coroner, but doesn't change the inquest outcome.
The most common way to challenge an inquest conclusion:
Section 13(1) sets out two situations. The first is where the coroner "refuses or neglects to hold an inquest or an investigation which ought to be held". The second is where an inquest has been held and it is "necessary or desirable in the interests of justice" that a further investigation should be held, by reason of:
The words "or otherwise" matter: the list is not closed. What the court has to be satisfied of is that a further investigation is necessary or desirable in the interests of justice.
No official statistics are published on how many section 13 applications are made or how many succeed. Earlier versions of this page gave annual figures for the Attorney General; they were not sourced and have been removed. The Attorney General's Office is the body to ask.
No published figures exist for how long a section 13 application takes, or for how long a fresh inquest takes once ordered. For context, the Ministry of Justice puts the average time to process an ordinary inquest at 31.3 weeks in 2025, from the report of the death to the conclusion.
No official source publishes what a section 13 application costs, so this page does not estimate it. Two things are on the record:
Judicial review is a challenge to the lawfulness of what a coroner did. It is often used against procedural decisions, but a conclusion can be quashed too where it is legally flawed — the court is not reviewing whether it agrees with the outcome, but whether the coroner was entitled to reach it.
You must show the coroner's decision was:
Judicial review must be brought "promptly" and in any event within 3 months of the decision. Delay can be fatal to your case even if you have good grounds.
Judicial review carries significant costs risks:
For less serious concerns, the complaints process may be more appropriate:
When to use:
Process:
Outcome: Chief Coroner can provide guidance to coroners but cannot overturn decisions or order new inquests.
When to use:
Process:
Outcome: Can result in advice, warning, or in serious cases, removal from office. Doesn't change inquest outcome.
Before formal complaints, consider raising concerns directly with the coroner or senior coroner. Many issues can be resolved through direct communication.
Important factors to consider before pursuing a challenge:
Consult with a specialist inquest solicitor who can objectively assess your prospects. Organizations like INQUEST can help you find appropriate legal advice and may be able to assess whether you have grounds for challenge.
Sometimes alternative approaches achieve better results than challenging the inquest:
If your goal is compensation for negligence or wrongdoing, civil litigation may be more effective than challenging the inquest. Civil courts aren't bound by inquest conclusions.
If you believe a crime was committed, report to police or CPS. They make independent decisions about prosecution regardless of inquest conclusions.
Complain to professional bodies (GMC, NMC, etc.) about professional conduct. They investigate independently of inquests.
Report workplace safety concerns to HSE. They can prosecute employers regardless of inquest conclusions.
If your goal is systemic change, public campaigning may be more effective than legal challenges. Prevention of Future Deaths reports already highlight systemic issues.
If you've decided to pursue a challenge:
Most challenges are unsuccessful. If your challenge fails:
What happens next: a refusal of permission for judicial review can sometimes be renewed or appealed, on advice. A refusal by the Attorney General to grant a fiat is not itself an inquest outcome. Ask your solicitor what, if anything, remains open.
Pursue alternatives: Consider civil litigation, professional complaints, or campaigning instead.
Seek closure: At some point, continuing to fight prevents healing. Bereavement counseling can help.
Channel energy positively: Some families find meaning in campaigning for systemic change rather than focusing on their specific case.
Before embarking on a challenge, understand these realities:
Scotland has no coroners and no inquests, so section 13 of the Coroners Act 1988 does not apply and neither does anything else on this page. Deaths are reported to the Procurator Fiscal, and a Fatal Accident Inquiry under the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016 produces a determination by a sheriff. A Scottish solicitor is the right source on what can be done about one.
Northern Ireland has coroners, but under the Coroners Act (Northern Ireland) 1959. Section 14 of that Act gives the Attorney General for Northern Ireland power to direct a coroner to hold an inquest where they have reason to believe a person died in circumstances that make an inquest advisable — a different mechanism from section 13 of the Coroners Act 1988, which does not apply in Northern Ireland.