Inquests in England and Wales

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Inquests in England and Wales are held into sudden and unexplained deaths and also into the circumstances of discovery of a certain class of valuable artefacts known as "treasure trove". In England and Wales inquests are the responsibility of a coroner, who operates under the jurisdiction of the Coroners and Justice Act 2009.

Where an inquest is needed[edit]

There is a general duty upon every person to report a death to the coroner if an inquest is likely to be required. However, this duty is largely unenforceable in practice and the duty falls on the responsible registrar. The registrar must report a death where:[1]

  • The deceased was not attended by a doctor during their last illness
  • The cause of death has not been certified by a doctor who saw the deceased after death or within the 14 days before death
  • The cause of death is unknown
  • The registrar believes that the cause of death was unnatural, caused by violence, neglect or abortion, or occurred in suspicious circumstances
  • Death occurred during surgery or while under anaesthetic
  • The cause of death was an industrial disease

The coroner must hold an inquest where the death was:[2]

  • Violent or unnatural
  • Sudden and of unknown cause
  • In prison or police custody

Where the cause of death is unknown, the coroner may order a post mortem examination in order to determine whether the death was violent. If the death is found to be non-violent, an inquest is unnecessary.[2]

In 2004 in England and Wales, there were 514,000 deaths of which 225,500 were referred to the coroner. Of those, 115,800 resulted in post-mortem examinations and there were 28,300 inquests, 570 with a jury.[3] In 2014 the Royal College of Pathologists claimed that up to 10,000 deaths a year recorded as being from natural causes should have been investigated by inquests. They were particularly concerned about people whose death occurred as a result of medical errors. "We believe a medical examiner would have been alerted to what was going on in Mid-Staffordshire long before this long list of avoidable deaths reached the total it did," said Archie Prentice, the pathologists' president.[4]


A coroner must summon a jury for an inquest if the death was not a result of natural causes and occurred when the deceased was in state custody (for example in prison, police custody, or whilst detained under the Mental Health Act 1983); or if it was the result of an act or omission of a police officer; or if it was a result of a notifiable accident, poisoning or disease.[5] The senior coroner can also call a jury at his or her own discretion. This discretion has been heavily litigated in light of the Human Rights Act 1998, which means that juries are required now in a broader range of situations than expressly required by statute.

Scope of inquest[edit]

The purpose of the inquest is to answer four questions:[6][7][8]

  • Identity of the deceased
  • Place of death
  • Time of death
  • How the deceased came by his/her death

Evidence must be solely for the purpose of answering these questions and no other evidence is admitted.[7] It is not for the inquest to ascertain "how the deceased died" or "in what broad circumstances", but "how the deceased came by his death", a more limited question.[7] Moreover, it is not the purpose of the inquest to determine, or appear to determine, criminal or civil liability, to apportion guilt or attribute blame.[9] For example, where a prisoner hanged himself in a cell, he came by his death by hanging and it was not the role of the inquest to enquire into the broader circumstances such as the alleged neglect of the prison authorities that might have contributed to his state of mind or given him the opportunity.[7] However, the inquest should set out as many of the facts as the public interest requires.[10]

Under the terms of article 2 of the European Convention of Human Rights, governments are required to "establish a framework of laws, precautions, procedures and means of enforcement which will, to the greatest extent reasonably practicable, protect life." The European Court of Human Rights has interpreted this as mandating independent official investigation of any death where public servants may be implicated. Since the Human Rights Act 1998 came into force, in those cases alone, the inquest is now to consider the broader question "by what means and in what circumstances".[11]

In disasters, such as the King's Cross fire, a single inquest may be held into several deaths. However, when several protesters were shot and killed by police in Mitchelstown in 1887, the findings of a common inquest were quashed because the killings had taken place at different times and in different places.[12][13]


Inquests are governed by the Coroners Rules.[14][15][16] The coroner gives notice to near relatives, those entitled to examine witnesses and those whose conduct is likely to be scrutinised.[17] Inquests are held in public except where there are real issues of national security.[18]

Individuals with an interest in the proceedings, such as relatives of the deceased, individuals appearing as witnesses, and organisations or individuals who may face some responsibility in the death of the individual, may be represented by lawyers at the discretion of the coroner.[19] Witnesses may be compelled to testify subject to the privilege against self-incrimination.[20]


The following verdicts are not mandatory but are strongly recommended:[21]

In 2004, 37% of inquests recorded an outcome of death by accident / misadventure, 21% by natural causes, 13% suicide, 10% open verdicts, and 19% other outcomes.[3]

Since 2004 it has been possible for the coroner to record a narrative verdict, recording the circumstances of a death without apportioning blame or liability. Since 2009, other possible verdicts have included "alcohol/drug related death" and "road traffic collision". The civil standard of proof, on the balance of probabilities, is needed for most verdicts, except unlawful killing and suicide where the criminal standard of beyond reasonable doubt is required.[22]


Owing in particular to the failures to notice the serial murder committed by Harold Shipman, the Coroners and Justice Act 2009 modernised the system with:

  • Greater rights of bereaved people to contribute to coroners' investigations;
  • A new office of chief coroner to lead and supervise practice;
  • Full-time coroners with new district boundaries;
  • Broader investigatory powers for coroners;
  • Improved medical support for coroners' investigation and decision making;
  • Vesting of treasure jurisdiction in the new office of treasure coroner with national responsibility.

See also[edit]


  1. ^ Halsbury vol.9(2) 949-950
  2. ^ a b Halsbury vol.9(2) 939
  3. ^ a b Department for Constitutional Affairs (2006)
  4. ^ "10,000 deaths a year from natural causes 'need examining by coroners'". Guardian. 27 August 2014. Retrieved 27 August 2014. 
  5. ^ Coroners and Justice Act 2009, s.7(2)
  6. ^ Halsbury vol.9(2) 988
  7. ^ a b c d R v. HM Coroner for North Humberside and Scunthorpe, ex parte Jamieson [1995] QB 1 at 23, CA
  8. ^ Coroners Rules 1984, SI 1984/552, r.36
  9. ^ Coroners Rules 1984, SI 1984/552, r.42
  10. ^ R (on the application of Davies) v. Birmingham Deputy Coroner [2003] EWCA (Civ) 1739, [2003] All ER (D) 40 (Dec)
  11. ^ R (on the application of Middleton) v. West Somerset Coroner [2004] UKHL 10, [2004] 2 AC 182, [2004] 2 All ER 465
  12. ^ Halsbury vol.9(2) 991
  13. ^ Re Mitchelstown Inquisition (1888) 22 LR Ir 279
  14. ^ Coroners Rules 1984, SI 1984/552
  15. ^ Coroners (Amendment) Rules 2004, SI2004/921
  16. ^ Coroners (Amendment) Rules 2005, SI2005/420
  17. ^ Halsbury vol.9(2) 976
  18. ^ Coroners Rules 1984, SI 1984/552, r.17
  19. ^ Coroners Rules 1984, SI 1984/552, r.20
  20. ^ Coroners Rules 1984, SI 1984/552, r.22
  21. ^ Halsbury vol.9(2) 1030
  22. ^ Coroner, Legal Guidance, Crown Prosecution Service

External links[edit]