Summary

An inquest is a fact-finding exercise that is conducted by the Coroner and, in some cases, in front of a jury. The purpose of an inquest is to find out who the person was and, how, when and where they died. This factsheet gives further information about what happens at an inquest.

What is an inquest?

An inquest is an inquisitorial proceeding, to find out:

• Who the deceased was
• When, where and how the deceased died

This is a public inquiry by a Coroner as opposed to a trial – which means there are no formal allegations or pleadings.

When is an inquest necessary?

In seeking to establish the cause of death, the Coroner will make whatever enquiries are necessary in the particular circumstances of the case, for example by ordering a post-mortem examination and/ or by obtaining medical records and witness statements.  The Coroner has a broad discretion in determining whether an inquest is required.  It may take some time before the Coroner’s investigation is complete and the decision with respect to the holding of an inquest is made.  This is particularly the case in circumstances where a person has died following complex medical treatment.

Most deaths that are reported to the Coroner do not result in an inquest being held.

Giving evidence at an inquest

Evidence is given by witnesses under oath, which means that you are under a legal obligation to tell the truth at an inquest (see the MPS factsheet on Giving evidence).

It is not a function of the Coroner to apportion blame – the Coroner’s court is one of investigation and inquiry; it is not meant to be adversarial.

However, questions from the Coroner can be challenging and interested persons have the right to legal representation. If you are employed by a healthcare organisation such as a hospital Trust, your employer may arrange legal representation to protect the interests of the healthcare body. Legal assistance is usually extended to include individual staff members involved in the management of a patient in the NHS. If you are self-employed – for example, in general practice – or in cases where there is a potential conflict between your interests and those of your employer, separate representation can be provided through MPS.

Obligation to notify the GMC if criticised by an official inquiry

The GMC publication Good Medical Practice includes an obligation (set out at paragraph 75[a]) for a doctor to inform the GMC (without delay) in circumstances when they have been criticised by an official inquiry (which would include a coroner’s inquest).

GMC guidance

The GMC advises doctors that they must cooperate with formal inquiries and must be honest and trustworthy when giving evidence. You must make sure that any evidence you give or documents you write, or sign, are not false or misleading. You must also make clear the limits of your competence and knowledge when giving evidence or acting as a witness. 

Two key points:

• You must take reasonable steps to the check the information
• You must not deliberately leave out relevant information.

Jury inquests

A jury will usually be required if the inquest is regarding a death in custody or a death which may involve a breach of Government regulations such as health and safety. It will also be required where deaths occurred in circumstances which may affect the health and safety of the public; or where the Coroner thinks that it is necessary to have a jury.

A jury is composed of individuals chosen at random from the Electoral Register and is made up of at least seven and not more than eleven people.

Outcome of the Inquest

The Coroner records the essential facts concerning the circumstances in which the deceased came by his or her death, in the form of “findings”, rather than in the form of a “verdict” (which is the case in England and Wales). 

The Coroner can refer a doctor or doctors to an appropriate body, for example the General Medical Council. If the Coroner considers that it would prevent a recurrence of the incident that caused the death.

Standard of proof required at an inquest

The standard of proof applied at an inquest is the civil standard – the Coroner and jury must be sure that it was more likely that not (on the balance of probabilities) that the facts have been found proven to support the “findings”.

What happens at an inquest?

An inquest is held in public and is a formal proceeding. Unlike a court case, there is no prosecution and defence. However, the witnesses may be represented by lawyers.

The Coroner decides who to call as a witness. As part of his investigation, the Coroner will request a statement, known in legal terminology as a ‘deposition’, from you and may call you as a witness at the inquest. If you are called as a witness, the Coroner may ask you to read through your statement, or may take you through the deposition  in court. You may be asked to produce a report and may not be called as a witness if your evidence is unlikely to be controversial.

“Properly Interested persons” are permitted to ask questions. The Coroner will decide who can undertake this function and persons with a ‘proper interest’ may include the relatives or personal representatives of the deceased. The questions will not be in the nature of a cross-examination, as in other courts. You are not obliged to answer the questions if the answer would incriminate you. If you do not know the answer, or understand the question, you should say so. If the Coroner is not satisfied that all the information is available at the inquest, or the appropriate witnesses are not available at the inquest or there is to be a police investigation into a possible crime, the inquest may be adjourned.

Recommendations from the Coroner

If an inquest raises concerns about the possibility of future deaths, the Coroner may report the matter to the person or authority with the power to take action to prevent a recurrence.

Additionally, where the inquest demonstrates that a criminal offence may have been committed, the Coroner is required to send a written report to the Public Prosecution Service.

Further information

• www.coronersni.gov.uk
• GMC, Good Medical Practice, par 75 [a]
• Coroners Act (Northern Ireland) 1959
• GMC, Good Medical Practice, par 72 
• GMC, Acting as a Witness in Legal Proceedings, explanatory guidance, Good Medical Practice, (2013)