What Happens at an Inquest

Understanding Coroner Inquests

An inquest is a legal inquiry held by a coroner to establish who died, when and where they died, and how they came to their death. Inquests are public hearings and can feel formal and daunting, but understanding the process can reduce anxiety and help you participate effectively.

October 2025 Update:

Many coroner's courts now offer remote attendance options for preliminary hearings and some full inquests. Family members can request to attend via video link if traveling would be difficult.

Key Point: An inquest is not a trial. It doesn't determine guilt or blame. Its purpose is to establish the facts surrounding a death and reach a conclusion about how it occurred.

When Inquests Are Held

Not all coroner investigations lead to an inquest. An inquest is mandatory when:

The death was violent or unnatural
The cause of death is unknown after post-mortem
Death occurred in prison, police custody, or state detention
Death may have resulted from an action or omission of the state

Many coroner investigations don't require an inquest. If the post-mortem establishes a natural cause of death clearly, the coroner will issue paperwork allowing registration without a hearing.

The coroner has discretion to hold an inquest in other circumstances if they believe one is needed to properly investigate the death.

Types of Inquests

Documentary Inquests

Conducted without a hearing, based on written evidence only. Used when the facts are straightforward and uncontested. Family is notified of the conclusion by post.

Inquest with Hearing (Standard)

A court hearing where evidence is presented and witnesses may be called. Most inquests fall into this category. Typically lasts half a day to two days.

Inquest with Jury

Some inquests require a jury (usually 7-11 people) who reach the conclusion. Mandatory for:

Deaths in custody
Deaths resulting from actions of police or other state agents
Deaths involving health and safety at work
Deaths that may affect public health or safety

Article 2 Inquests

Enhanced inquests examining whether the state has met its duty to protect life. These are more detailed and can take weeks. Required when state agents may have contributed to the death.

Before the Inquest: Pre-Inquest Review

For complex cases, there may be one or more pre-inquest review hearings:

Purpose of Pre-Inquest Review

Identify what evidence needs to be gathered
Determine who should be called as witnesses
Discuss timing and logistics
Address legal representation requests
Set the scope of the inquest

Family Involvement

You'll be notified of pre-inquest reviews and can attend. This is an opportunity to raise concerns about what should be investigated or suggest witnesses.

The Inquest Hearing: Step by Step

1. Opening

The coroner opens the inquest, introduces themselves and any jury, explains the purpose of the inquest, and outlines what will be covered. They'll emphasize that the inquest is not about blame.

2. Evidence Presentation

The coroner (or coroner's lawyer) presents documentary evidence:

Post-mortem report
Medical records
Police reports and statements
Other relevant documents

3. Witness Evidence

Witnesses are called to give evidence under oath. This might include:

Pathologist who conducted the post-mortem
Doctors or medical staff who treated the deceased
Police officers who investigated
Family members who were present
Witnesses to the events leading to death
Expert witnesses on relevant topics

4. Questioning

After each witness gives evidence:

The coroner asks questions
Lawyers representing interested persons can ask questions
Family members can ask questions (either directly or through the coroner)
Jury members can request questions be asked

5. Summing Up

The coroner summarizes the evidence heard and explains the legal framework for reaching a conclusion. For jury inquests, the coroner directs the jury on the law.

6. Verdict/Conclusion

The coroner (or jury) reaches a conclusion about how the person died. The coroner may also make a Prevention of Future Deaths report if they identify systemic issues.

Who Can Attend an Inquest

Inquests are public hearings unless the coroner orders otherwise:

Interested Persons

Certain people have legal status as "interested persons" with enhanced rights:

Close family members (spouse, partner, children, parents, siblings)
Personal representatives (executors)
Anyone who may have caused the death
Organizations that may have contributed (e.g., employers, hospitals)
State bodies involved (e.g., police, prison service)

Public Attendees

Anyone can attend an inquest as a member of the public, including friends, journalists, and researchers, unless the coroner restricts access for specific reasons.

Media

Journalists often attend inquests. The coroner can restrict reporting in some circumstances, but most inquests are publicly reported.

Your Rights as Family

As an interested person (family member), you have specific rights:

Right to disclosure: See relevant documents and evidence before the inquest
Right to question witnesses: Either ask questions yourself or through a lawyer
Right to suggest witnesses: Propose who should be called to give evidence
Right to raise concerns: Highlight issues you believe should be investigated
Right to legal representation: Instruct a lawyer to represent you (though you may need to pay privately)
Right to be heard: Make submissions to the coroner about the conclusion

Important: You don't have to actively participate. Some families choose to attend and listen without asking questions, which is entirely appropriate.

Legal Representation at Inquests

Whether to have a lawyer represent you at an inquest:

When You Might Need a Lawyer

Complex medical or technical evidence
Potential systemic failures (hospital, care home, police)
Article 2 (state duty) inquests
Multiple organizations are represented by lawyers
You want to question witnesses in detail
The circumstances are contentious or disputed

Funding Legal Representation

Legal representation can be expensive:

Legal aid: Available for some Article 2 inquests
Public funding: Exceptional case funding in limited circumstances
Pro bono: Some law firms offer free representation for deserving cases
Private funding: Most families must pay privately (£3,000-£15,000+ depending on complexity)

Support Organizations

Charities like INQUEST provide free advice and can sometimes help with representation or connect you with pro bono lawyers.

Preparing for the Inquest

How to prepare yourself and your family:

Read disclosed documents: Review all evidence the coroner has shared so you understand what happened.
List your questions: Write down what you want to understand better or what concerns you.
Decide who will attend: Discuss with family who wants to be present and whether to bring support.
Visit the court beforehand: Many coroner's courts allow you to visit in advance to familiarize yourself.
Consider support: Bring a friend or family member for emotional support (they can sit with you).
Plan practical details: Know where the court is, parking, travel time, and whether breaks are scheduled.
Prepare emotionally: Understand that hearing detailed evidence about the death will be difficult.

What to Expect on the Day

The Setting

Coroner's courts vary. Some are formal courtrooms, others are more informal hearing rooms. The coroner sits at the front, witnesses give evidence from a witness box or table, and family usually sits in a designated area.

Timing

Inquests typically start at 10am or 2pm. Simple inquests may be over in a few hours. Complex ones can last days or weeks. You don't have to stay for every moment if it becomes too overwhelming.

Emotional Impact

Hearing clinical details about your loved one's death is distressing. Coroners understand this and usually allow breaks if you need them. It's okay to leave the room temporarily.

Support Available

Most coroner's courts have support staff who can show you where to sit, explain procedures, and provide practical help. Some have family liaison officers or counseling support available.

After the Inquest

What happens once the inquest concludes:

The Record of Inquest

The coroner provides a formal document (Record of Inquest) stating their conclusions. You'll receive a copy and can order additional certified copies for legal purposes.

Registration

If the death wasn't already registered, the coroner sends the Record of Inquest to the registrar, allowing you to register the death and receive death certificates.

Prevention of Future Deaths Reports

If the coroner identifies ways to prevent similar deaths, they'll send a report to relevant organizations, who must respond within 56 days. You'll receive copies of these reports and responses.

Further Action

The inquest conclusion may inform:

Criminal prosecutions (though the inquest itself doesn't determine guilt)
Regulatory action against professionals
Civil claims for compensation
Internal investigations by organizations

Questions You Can Ask

When questioning witnesses, focus on understanding what happened:

Helpful questions:

"Can you explain what treatment was provided?"
"What were the symptoms that caused concern?"
"When was the decision made to...?"
"What guidelines or procedures should have been followed?"
"Were there any warning signs that were missed?"

Questions the coroner won't allow:

Questions that imply blame or guilt
Questions about who should be punished
Questions about civil compensation
Argumentative or repetitive questions
Questions seeking opinions on matters beyond the witness's expertise

Coping with the Inquest Process

Inquests can be traumatic experiences:

Allow yourself to feel upset – it's a normal reaction to hearing difficult details
Don't attend alone – bring supportive family or friends
Take breaks when you need them
Consider counseling support before and after the inquest
Remember the inquest serves an important purpose in understanding what happened
Focus on what you can learn rather than dwelling on what can't be changed
Connect with support organizations who understand the process

Key Takeaways

• Inquests establish facts, not blame
• They're public hearings that family can attend and participate in
• You have rights to see evidence and question witnesses
• Legal representation isn't required but can be helpful in complex cases
• The process can be emotionally difficult – bring support
• Coroners are generally understanding and accommodating to family needs
• The outcome helps prevent future deaths and provides closure

Support and Resources

• INQUEST: 020 7553 0174 / inquest.org.uk – Free advice for bereaved families
• Local Coroner's Office: Contact them with questions about your specific inquest
• Victim Support: 0808 1689 111 – Emotional support
• Cruse Bereavement Support: 0808 808 1677
• Citizens Advice: Free advice on legal processes

Scotland and Northern Ireland

Scotland

Scotland has a different system. Fatal Accident Inquiries (FAIs) serve a similar purpose to inquests but have different procedures. Contact the Procurator Fiscal for information.

Northern Ireland

Northern Ireland has a coroner system similar to England and Wales, with broadly comparable inquest procedures.