In England and Wales the Coroner must be informed of any death within their jurisdiction that is sudden, unnatural, unexplained or for which a doctor has been unable to certify a cause of death.
The Coroner must establish four facts; who has died, when, where and how. If there is any doubt about any of these things then the Coroner must hold a Coroner's Inquest.
An inquest is a public hearing where the facts which are in doubt are looked into so that the Coroner can reach his conclusions.
The Coroner should open the Inquest as soon as possible but will often adjourn proceedings so that the full hearing is postponed until a later date, therefore allowing the Coroner to undertake detailed enquiries into the circumstances of the death.
Once all of the necessary investigations have taken place, the Coroner will set a date for the full Inquest.
Properly Interested Parties
An Inquest is conducted by the Coroner but other parties are able to participate if they are a ‘properly interested party’.
Close relatives of the deceased such as a spouse or a parent will always qualify as a ‘properly interested party’.
If a person or party is implicated in the death then they too will qualify as a properly interested party.
Properly interested parties or their legal representatives are allowed to question witnesses at the Inquest hearing.
It is common for a Coroner to hold a Pre-Inquest Hearing. These are meetings at which the Coroner will set out the scope of the Inquest and will make important decisions about the inclusion of witnesses and the need for any further investigations.
The Pre-Inquest Hearing is an opportunity for the deceased’s relatives to communicate with the Coroner and to influence the scope of the final Inquest hearing.
Before the Inquest it is usual for the Coroner to provide copies of documents which are intended to be admitted as evidence to the properly interested parties.
However, at the beginning of the inquest the Coroner will give copies of any remaining documents to the properly interested parties as they may to object to the inclusion of any documentary evidence if the contents are open to dispute.
As well as documentary evidence, the Coroner will include oral evidence provided by witnesses. All witnesses will first be questioned by the Coroner. When the Coroner has finished asking questions the other properly interested parties can ask questions of the witness either themselves or via their legal representative. If the witness has legal representation then they will be the final person to ask questions of that witness.
Conclusion of the Inquest
Verdicts within Coroner’s proceedings are now known as conclusions. As was the case with the old verdicts, conclusions may not be framed in such a way as to appear to determine any criminal liability on the part of a named person or civil any liability on a person or party.
Reports to prevent future deaths
A coroner is now under a duty to report actions to prevent future deaths to a person who the coroner believes may have the power to take such actions.
The coroner must make a report where the investigation he or she has been conducting reveals something which gives rise to a concern that there is a risk of deaths in the future and that action should be taken to eliminate or reduce that risk.
The coroner may recommend that action should be taken, but not what that the action should be.