Inquest procedure
The pre-inquest review

The coroner will often set a preliminary directions hearing so that the agenda and timetable for the inquest can be discussed and agreed. This is known as a pre-inquest review (PIR). At this hearing, the coroner will:

  • state what he or she considers to be the main issues under investigation;
  • discuss who should be an interested person (formerly a party);
  • discuss the scope of the inquest;
  • look into whether Article 2 is engaged;
  • discover whether he or she needs to sit with a jury;
  • state who he/she wishes to seek evidence from;
  • state when the hearing is likely to be held; and
  • set out which documents he/she wishes to have access to, if he/she has not received these already.

Often, interested persons will be legally represented at a PIR as these issues can be contentious.

The inquest hearing

Most hearings will take place at the coroners court in the area where the deceased lived. The coroner opens the inquest hearing setting out what the inquest will focus upon, and how he/she will proceed. If there is a jury, they will be selected and sworn in. 

Usually, the coroner will hear evidence from the family to describe the deceased and to set out their main areas of concern. Following that he/she will then lead the questioning.

Once the coroner has questioned the witness(es), he/she will allow other interested persons to question the witnesses. If the family is not represented, they will usually nominate a family member to speak for the whole family. If there is a jury, then the jury will also put questions to the witnesses. 

At the end of the evidence, the coroner will invite advocates to make submissions on the likely and appropriate conclusion. At this stage, the coroner will also invite any submissions on the issue of neglect and RPDs.

Most inquests only take a day or two; although some can go on for a number of weeks.


The coroner will hear and read evidence (where it is not in dispute) from a variety of sources, in order to answer the four questions satisfactorily. Evidence from a pathologist, for example, will be sought to determine the medical cause of death and contributory factors, a family member may also be asked to give identification evidence and those having contact with the deceased in the days leading up to death will almost certainly be expected to give evidence. The coroner will decide who is going to give oral evidence and this will be given under oath or affirmation. Depending upon the issues, expert evidence may also be obtained to assist the coroner.

As mentioned above, in addition to witnesses, the coroner will identify who is an interested person. The status of the interested person is important as they have the right to ask questions of witnesses and to have full disclosure of relevant documents identified by the coroner. The most common interested person in a sheltered or supported housing setting will be the family, the RP’s staff on site and the care provider. Sometimes other professionals, such as the deceased’s GP or psychiatrist, will be called. The status of interested persons can also be an indication that the coroner considers there to be culpability on the part of the individual or organisation. There can be a conflict of interest between employer and employee. 

Regulators such as the Care Quality Commission or the Health and Safety Executive may be in attendance to hear the evidence or may ask to take part as an interested person. This allows them disclosure and the opportunity to question witnesses. 

For further information

Tim Coolican, is a Partner and regulatory lead and provides legal support throughout the inquest process. He has particular expertise 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. You can download a copy of the inquest process here.

For registered providers

Find out how we can support providers in social housing throughout the inquest process here, or see our inquest FAQs

For health and social care providers

Take a look at how we assist health and social care providers when they are aware of possible inquest here, or read our inquest FAQs.