Coroner Inquest Verdict: Can It Be Appealed or Changed?

An inquest verdict that feels wrong — one that attributes a death to natural causes when a family believes there was negligence, or records suicide when a family believes the death was accidental — can cause profound and lasting distress. Understanding what can actually be done about it is essential for families seeking to challenge a conclusion they believe is unjust. This guide explains the options available in England and Wales.

Why there is no formal appeal: the nature of inquest proceedings

An inquest is an inquisitorial process — it is not a trial, it does not apportion blame, and it does not determine civil or criminal liability. The coroner's role is to find out, on the balance of probabilities, who the deceased was and how, when, and where they came by their death. Because an inquest is not an adversarial proceeding with parties and judgments, there is no formal appeal mechanism built into the system.

This means that families who are dissatisfied with an inquest verdict cannot simply appeal to a higher court in the way they could appeal a county court judgment. The challenge must be made through judicial review — a legal process by which the High Court reviews the lawfulness of a public decision-maker's conduct, rather than re-hearing the evidence and reaching a different factual conclusion.

Judicial review is not about whether the coroner reached the "right" answer — it is about whether the coroner conducted the inquest in a lawful way. This distinction is fundamental and often frustrating for families who are convinced the facts support a different conclusion. The High Court will not simply substitute its view of the facts for the coroner's.

Grounds for judicial review: what can be challenged

To bring a judicial review challenge against an inquest verdict, there must be at least one arguable legal ground. The main grounds that have succeeded in inquest judicial reviews include:

• Procedural unfairness: the coroner failed to follow the correct procedures under the Coroners and Justice Act 2009 and the Coroners (Inquests) Rules 2013 — for example, failing to disclose relevant evidence to interested persons before the inquest
• Failure to consider relevant evidence: the coroner excluded evidence that was relevant to the inquest, or failed to call a witness who could have provided material evidence — and this may have affected the conclusion
• Wrong legal directions to a jury: where a jury sat at the inquest, the coroner misdirected the jury on the law — for example, giving the wrong direction on the standard of proof for a conclusion of suicide
• Conclusion not supported by the evidence: where the conclusion reached is one that no reasonable coroner, properly directing themselves on the law, could have reached on the evidence
• Bias: in exceptional cases, where actual bias or apparent bias is demonstrated — for example, a coroner who had a personal connection to an interested party
• Article 2 ECHR obligations not met: where the state may have been responsible for the death (for example, a death in custody or following NHS treatment), the inquest must meet the enhanced investigative duty under Article 2 of the European Convention on Human Rights — failure to do so is a distinct ground of challenge

Who can challenge: "interested persons" under the Coroners and Justice Act 2009

Not everyone can bring a judicial review of an inquest verdict — only those with a sufficient legal interest to do so (known as "standing" or "locus standi" in legal terms). In the inquest context, the relevant category is "interested persons" as defined in section 47 of the Coroners and Justice Act 2009.

Interested persons include:

• The spouse, civil partner, partner, parent, child, brother, sister, grandparent, grandchild, child of a brother or sister, stepfather, stepmother, half-brother, or half-sister of the deceased
• The deceased's personal representative (executor or administrator)
• Any beneficiary under a life insurance policy on the deceased's life
• The insurer who issued the policy
• Any person whose act or omission may have caused or contributed to the death of the deceased (for example, an employer where the death was work-related, or a healthcare provider)
• Any government department or chief officer of police if the deceased was in custody or state detention
• Any person appointed by a trade union to represent the deceased
• Any other person who the coroner thinks has a sufficient interest

For most bereaved families, the immediate family members will automatically qualify as interested persons. This also means they were entitled to participate in the inquest itself — to ask questions of witnesses, call their own witnesses, and be legally represented. If a family was denied these rights during the inquest, this itself may be a ground for challenge.

The Chief Coroner's powers: directing a fresh inquest

The Chief Coroner of England and Wales is a senior judge who has oversight of the coroner system. Under section 40 of the Coroners and Justice Act 2009, the Chief Coroner has the power to direct that a new inquest be held into a death if there is "sufficient reason" to do so. This is a separate power from judicial review and operates alongside it.

Making a complaint to the Chief Coroner is often a useful first step, even if judicial review is also being considered. The Chief Coroner's Office can be contacted at: Chief Coroner's Office, Royal Courts of Justice, Strand, London, WC2A 2LL, or through the Ministry of Justice website. Write a clear letter setting out:

• Who the deceased was and when and where the inquest took place
• The conclusion that was reached
• The specific reasons why you believe the inquest was conducted unlawfully or that a fresh inquest is required
• Any supporting documentation (transcripts, expert reports, evidence that was not considered)

The Chief Coroner does not have to act on every complaint, and the threshold for directing a fresh inquest is high. However, the process is less expensive and formal than judicial review, and the Chief Coroner's response may itself be informative about the merits of a judicial review challenge.

Quashing orders and fresh inquests: what happens if judicial review succeeds

If a judicial review of an inquest verdict succeeds, the High Court can quash the original inquest conclusion (technically the "record of the inquest") and order that a fresh inquest be held before a different coroner. This is the most common remedy in successful inquest judicial reviews.

A quashing order does not automatically produce a different outcome. The fresh inquest will hear all the evidence afresh (sometimes with new evidence that was not available at the first inquest) and reach its own conclusion. It is possible that a fresh inquest reaches the same conclusion as the original — or a different one. The remedy is to ensure the process is conducted lawfully, not to guarantee a particular verdict.

In cases involving Article 2 ECHR (deaths in custody, NHS deaths, or other state-related deaths), the High Court may also make declarations about the state's obligations and the inadequacy of the original investigation. These declarations can have wider significance beyond the individual case — they can prompt systemic changes and are sometimes the primary goal of families who have pursued a challenge.

The cost of bringing a judicial review challenge is significant. Legal aid may be available for families without means. The charity INQUEST provides specialist support, advice, and casework for bereaved families and can advise on legal aid eligibility and specialist solicitors.