Our understanding of the health and social care sector enables our team of inquest solicitors team to assist you, as a health and social care client, in your times of crisis. We offer you sensitive, practical advice, support and advocacy in relation to the increasingly complex area of coronial law and inquests, without the need to instruct counsel.
What is an inquest?

As every coroner will state at the opening of an inquest, an inquest is a fact-finding enquiry that will allow him or her to ascertain the answer to four questions:

  • who has died?
  • where did they die?
  • when did they die?
  • how did they die?

The inquest should not stray beyond this purpose, save for asking questions surrounding remaining concerns that, if unresolved, could give rise to future deaths.

Since the Human Rights Act 1998 came into force, the question of ‘how’ can include ‘by what means and in what circumstances’. In reality, the coroner can ask whatever questions he deems fit in order to ensure that:

  • the full facts are brought to light;
  • culpable and discreditable conduct is exposed and brought to the public notice;
  • suspicion of deliberate wrongdoing (if unjustified) is allayed;
  • dangerous practices are rectified; and
  • those that have lost their relative may, at least, have the satisfaction of knowing that lessons learned from their death may save the lives of others.

[Amin v Secretary of State]

Much will also depend upon the circumstances that prevailed prior to the death. If, for example, the deceased was being looked after by the state (i.e. someone lacking mental capacity), then the hearing will usually be heard before a jury, and will be wider in scope to comply with Article 2 of the Human Rights Act. This means that a care provider will be under scrutiny if someone dies whilst in its control, and it appears that the death was avoidable. There are a range of likely circumstances: a fall, choking, a question of whether the right medication was given, etc.

Background to the inquest process

Until the Coroners and Justice Act 2009 came into force in April 2010, inquests were considered to be something of a lottery and were very much dependent upon the approach of the individual coroner. This meant that the process could be confusing, and there was a lack of clarity regarding the likely outcome. Since the statutory creation of the role of chief coroner, there has been a push for uniformity in approach and conclusions (formerly verdicts). The system has become more streamlined in order to resolve the increasing backlog of hearings, and there is now guidance issued by the chief coroner to assist practioners. Despite this, inquests have become more complex and, as a result, there has been an increase in families and organisations involved in a death seeking legal advice and representation.

What happens at an inquest?

The inquest should follow an inquisitorial, rather than adversarial, process. However, inquests can be the only forum in which a family has the opportunity to raise questions directly to those who have been involved in the death of a loved one, and, for this reason, they can become heated if not controlled properly. Questioning will also be robust. Although the inquest is not a trial, for those giving evidence IT can be a stressful experience, especially where witnesses aren’t sure what to expect, are ill prepared and have not received the right support.

In addition to factual evidence given by individuals who have come into contact with the deceased, clients can expect their governance systems to be scrutinised—especially if there is a concern of systemic failure. These may include, for example, an analysis of staffing levels, observations and care plans. Sometimes concerns can only become apparent during evidence gathering.

Evidence may also be called from other, more peripheral bodies, such as the local authorities safeguarding team and health and social care professionals.

The inquest is nearly always held in public, which means that the press can, and often do, attend.

Find out more about the inquest process.

Do I have to go?

Sometimes a witness’ evidence can be agreed and it will not be necessary for that person to attend. However, key witnesses will be called to give oral evidence. The family’s wishes will be persuasive if they wish to push for the attendance of individuals. The coroner often issues a summons to ensure the attendance of a witness.

Am I in trouble?

As mentioned above, the inquest is not a trial. There are no parties, no indictment and no defence or prosecution, but interested persons will often be legally represented. Sometimes a regulatory body such as the General Medical Council or Nursing and Midwifery Council will provide representation for its members. 

The Coroners and Justice Act 2009 specifically prevents the determination of any civil or criminal liability, and a witness may be protected from giving self-incriminating evidence. 

Criminal proceedings can arise out of the circumstances explored by the coroner. If the coroner believes that a crime has been committed, then he/she should stop the proceedings to allow the Crown Prosecution Service to consider the issues and whether there is sufficient evidence for a prosecution.


If you are asked to attend an inquest, it is vital that you are well prepared. It is likely that you will have made a statement and you should read this before the hearing and take a copy with you, as you will be questioned on this.

Care plans, medical records and other relevant documentation will have been disclosed to the coroner (e.g. medical administration records). If these have a direct bearing on your evidence, consider them before you attend the hearing. You will need to be familiar with your organisation’s policies and record-keeping systems too. If you are not familiar, you will be asked why, if your training deficient and if the proper risk assessments have been undertaken. The more senior you are, the more technical questioning is likely to get.

What do I wear?

Wear something smart, as if you are attending an interview. You would not expect someone to attend a hearing about your loved one in casual clothing.

How do I address the coroner?

Sir or Madam.


The coroner is expected to consider whether [what is called] a short-form conclusion, would be appropriate. These include:

  • natural causes;
  • alcohol or drug related;
  • road traffic collision;
  • lawful/unlawful killing;
  • suicide; or
  • accident.

The burden of proof is generally on a balance of probabilities, but, sometimes, for unlawful killing, the criminal standard is applied.

If the coroner does not consider that a short-form conclusion will satisfactorily reflect the circumstances of death, then he/she will give a narrative conclusion. This is often the case where the death arises from more than one cause. The coroner cannot use words that suggest civil liability such as negligence, breach of duty or carelessness. However, he or she can use words such as inadequate, inappropriate, insufficient or failure.


Neglect is not a conclusion and is not the same as negligence. For the purposes of the inquest, the coroner will consider whether there is evidence of a gross failure to provide basic care to a person in a dependent position. Therefore, the case of an elderly person in a domiciliary care setting who was malnourished because care workers did not give basic care, could result in a finding of neglect in addition to a short-form conclusion. 

Reports for the prevention of future deaths

A crucial function of the coroner is the statutory duty to report on matters that give rise to concerns that, if not resolved, could lead to future deaths. The coroner will expect attendance from senior management to give evidence about lessons learned. Sometimes, this evidence is given after the evidence relating to the four questions. This is because it can be perceived to be prejudicial. 


The death of a service user can give rise to lengthy and wide ranging enquiries from other sources. In addition to the coroner and the family, the Care Quality Commission, Health and Safety Executive and the police may also be conducting investigations. Insurers will wish to know about the circumstances surrounding the death. A claim for compensation may be intimated, and there is the likelihood of reputational damage.

Naturally, it is only possible to give an overview of the inquest process and every case will be different. Anthony Collins Solicitors has the expertise to assist you throughout the inquest process, including advocacy. We can also assist with PACE (Police and Criminal Evidence) interviews and representations to other bodies, including regulators. 

For further information

Tim Coolican, our regulatory lead, supports health and social care clients. He has particular expertise as an advocate in inquests, including complex jury inquests with multiple interested persons. 

If you have any queries or concerns that you would like to discuss, please contact Tim Coolican, at Anthony Collins Solicitors, who will be happy to assist. To find out more about how we can support you during an inquest, please download our 'Legal support to health and social care clients during an inquest' guide or have a look at our inquest process infographic.