Coroners Inquest

Coroners Inquest, Investigations and funding.

The Area Coroner my open an inquest into any death. A coroners inquest is just another word for investigation. The inquest should not be seen as a precursor to a prosecution or to a civil claim for negligence. That however, does not mean that a criminal prosecution may follow. It just means it that neither of these things are “dependent” upon an inquests outcome. 

For a family or loved ones an inquest is a first stage which may well provide valuable answers.  

The Coroner wishes to establish just 4 things from the inquest – The name of the deceased – The place of their death – The time of their death – How the death occurred. The inquest is not a trial and should not be treated as one.

Dealing with an inquest and with the expert witnesses called to give evidence is not easy, it should not be tackled by the family but instead they should hire a suitable advocate. At Law – Med Solicitors we have been active in investigations that cover all manner of deaths including those that were followed up by criminal prosecutions and even public inquiries. Call today to discuss your situation further. 

Public funding in the form of Legal Aid can be used  in some instances, such as where the death occurred in a HMP establishment or if the deceased was formally sectioned under the Mental Health Act. There are some instances where public funding can be made available but these are generally those instances where there is a large public concern, such as a Aircraft Disaster or more recently the Grenfell Tower Fire. 

Whilst there is no obligation to instruct a solicitor for a coroners inquest, you may find that the Hospital or other agencies involved in the action have several lawyers present. In addition there are likely to  medical experts to assist the coroner and these may well communicate in formal medical language, they are there after all to answer the coroners questions and not necessarily to assist the family.

As well as these experts there is likely to be evidence from the deceased GP and the various physicians that have treated the deceased prior to death. Finally it is likely that the coroner will want to hear from the pathologist who performed the autopsy. All of these witnesses can be cross examined but how they are approached is the main issue.

What is a Coroner

Its an ancient office but essentially a  coroner is an independent judicial officer appointed by the local authority with the consent of the Chief Coroner. The Coroner must be an experienced lawyer.  Most coroners have coroner’s officers to assist them.  Coroner’s officers are usually ex police officers and they work under the direction of the Coroner and liaise with the witnesses, pathologists, toxicologists, medical experts etc. The purpose of the investigation is to fulfill the questions raised in the coroners inquest.

What are the responsibilities of a Coroner

When someone dies the death must be registered. A doctor can issue a medical certificate stating the cause of death, however, if the doctor feels he cannot issue the certificate then the matter proceeds to a coroner.  If a post-mortem establishes the cause of death then the Coroner will send a form to the Registrar of Births and Deaths stating it and then you will be able to make an appointment to register the death. If it was not possible to establish the cause of death or the death is found to be unnatural the coroner again must open an inquest into the fatality. A coroner must conduct an inquest into a person’s death where there is reasonable cause to suspect that the deceased has died a violent death, an unnatural death, a sudden death where the cause is unknown, where a death occurs in custody or in certain other circumstances.

What is a Coroners Inquest

A coroners inquest is a public court hearing. It is held by the Coroner in order to establish who died and how and where and when occurred.  An inquest is a investigation, not a trial. The coroner ensures the process is  fair and thorough. The purpose of an inquest is set out in section 11 of the Coroners Act 1988. The rules governing an inquest are set out in The Coroner’s Rules 1984 .

The Coroner opens the inquest soon after a person dies in order to record that a death has occurred. Then the Coroner will identify the deceased and enable the coroner to issue authority for the body to be released for burial or cremation. The inquest will then be adjourned for investigation to be completed. Once the investigation is complete, the inquest will be resumed and concluded.  The inquest will be held as soon as possible and it is aimed to be within 6 months (it rarely is). When a date is set for the inquest, the family and witnesses are asked to attend to give evidence.

What are the Coroners Inquest Verdicts

The verdicts available to a coroner are typically ; Accident or misadventure , Alcohol or drug related, Industrial disease, Lawful killing, Unlawful killing, Natural causes, Open, Still birth, Road traffic accident and Suicide. Although in many circumstances the coroner will record a narrative verdict which sets out in more detail how the death came about. 

What is an Article 2 Coroners Inquest

An Article 2 Coroners Inquest relates to Article 2 of the European Convention on Human Rights. The ECHR protects the right to life. The European Court of Human Rights has declared that “Article 2 ranks as one of the most fundamental provisions in the Convention”. Members are obliged to abide by three key aspects of this convention. These aspects are: the duty to refrain from unlawful deprivation of life, the duty to investigate suspicious deaths; and in certain circumstances, a positive obligation to take steps to prevent avoidable losses of life.

That investigation must be ‘effective, independent and prompt’.”  The leading case on this is Salman v Turkey (2000). The judgement states that: “Where the events in issue lie wholly, or in large part, within the exclusive knowledge of the authorities, as in the case of persons within their control in custody, strong presumptions of fact will arise in respect of injuries and death occurring during such detention.  When becoming involved with the legal proceedings relating to an Article 2 Inquest at the Coroners Court it is advisable to have access to qualified legal representation. 

Will I have to give evidence in Court

The Coroner has wide ranging powers to call people to give evidence at a hearing however, in most circumstances the purpose of the coroners inquest is satisfied by expert evidence and witness evidence of those who were present at the last moments.

Mr Graham G Balmforth

A Solicitor and Higher Court Advocate with a background in forensic medical sciences, Mr Balmforth represents families at a wide range of inquest hearings including Inquests held before a jury and article 2 inquests.

In a 1 week Coroners inquest before a Jury, the death of a South Wales schoolboy was investigated. The consequence of the inquest, which was led on behalf of the boys family by Mr Graham Balmforth was a full investigation and prosecution by the Health and Safety Executive of the local authority. That investigation resulted in a Crown prosecution for significant mismanagement and breaches of Health and Safety. The authority was able to evade a substantive fine only because of the hardship that this would impose on the community. The inquest and subsequent investigation however sparked a debate in the Welsh Parliament regarding Public Finance Initiatives and a design safety. A nationwide review of schools health and safety particularly with regard to onsite traffic management followed. The report of the incident is listed in the below video.

Solicitor Advocate appears at South Wales Jury Inquest

Useful Links

Coroners Society