Losing a loved family member is devastating and it can leave family and friends with questions about the death and why it happened.

Sometimes, the circumstances surrounding the death of an individual will trigger the need for an investigation.

An inquest is a formal legal investigation into the circumstances leading up to a person’s death. Inquests are not held as a matter of course and are required only at the direction of the local Coroner. Inquests are held in cases where:

  • The death was sudden, violent or unnatural
  • The death occurred in police custody or in prison
  • The cause of death is still unknown even after a post mortem, or
  • The death occurred in any place or in such circumstances as to require an inquest in accordance with any statute

Inquests are often held in the event of fatal road traffic incidents or other accidents. Occasionally, inquests are held to examine the medical care or treatment provided, if the death was relatively sudden following that care or treatment.

Because of the nature of the investigation, families of the deceased often find the process extremely informative in understanding details surrounding the death of their loved one. An inquest provides an opportunity to ask professionals who may be involved, e.g. police or other emergency services, what happened. These professionals may be experts in their field and it may be useful to ask them what they envisage were the circumstances leading up to the death.


It is important that the right information is obtained and the right questions are asked at the inquest. Solicitors are able to provide representation to families or other interested parties at inquests, to support and assist at a very difficult time.


Examining the circumstances of death means that the Coroner will try to establish:

  • who has died
  • when they died
  • how they died, and
  • why they died

The sole purpose of an inquest is to understand the circumstances of the death. It is not to apportion blame.

An inquest is formally declared open soon after death occurs, and steps are then taken by the Coroner to gather information. Evidence usually takes the form of statements, diagrams and plans, depending on the circumstances. Common contributors to the evidence are Police officers, paramedics, Fire Service officers, social workers, family members and any other lay witnesses to the circumstances of the death.

Individuals will submit witness statements to the Coroner. The Coroner will then decide if the circumstances require a full hearing, with the attendance of witnesses, or whether the witness statements can be taken “as read” without the need for the attendance of witnesses.

If the Coroner decides that a full hearing needs to take place, a date will be set and witnesses will normally be summoned to attend.

Normally, the Coroner will sit without a jury and conduct the proceedings. Witnesses will be invited to read their statements aloud unless they prefer them to be read out by another person. The Coroner will then put questions to each witness to understand the circumstances of the death. Witnesses are not obliged to answer any questions which could lead to self-incrimination.

The Coroner will be seeking to understand, for example:

  • In the case of a road traffic accident, the precise timings, road conditions and any relevant factors;
  • In the case of a drug-related death, the lifestyle of the deceased. The Coroner will want to speak to witnesses who had last contact with the deceased
  • In the case of a sudden unexplained death following a medical procedure, the treatments given and the clinical decisions taken by the medical staff

The Coroner is not looking to investigate who was at fault, nor is the Coroner looking to apportion blame. Indeed, the Coroner is not allowed in the verdict to say whose fault it was or who was to blame.


At the end of the inquest, the Coroner will come to a conclusion. The Coroner will confirm the identity of the deceased and the time and place of the death. The Coroner will also confirm the date, cause of death, generally placing the death in a category such as “suicide”, “natural causes” or “accident”.

In cases where the circumstances are more complex, particularly those involving industrial disease, connected with medical care or in the case of an unlawful killing, Coroners can now give a brief narrative conclusion setting out the facts surrounding the death. Such a narrative does not include any apportionment of blame but acts as a summary of the factors considered to have led to the death. The narrative can later be important in considering the potential for civil claims.

A verdict of accidental death or even of neglect does not necessarily mean that there is sufficient evidence to support civil cases.


Coroners have powers to make recommendations for the future safety of the public. For example in the case of a road traffic accident, if concerns have been raised as to the particular safety of a junction, the Coroner can write to the Highway Authorities and make recommendations.

This public role is a key element of the position of the Coroner in our society and reflects the origin of the Coroner’s role in this country. The role of the Coroner evolved hundreds of years ago because of the considered belief by the Crown that suspicious deaths must be investigated for reasons of public safety and standards.