Medical Negligence Inquests

You probably have a lot of questions, not just about what happened to your loved one, but also what to expect from the inquest process.

When are inquests held?

In certain circumstances when a person dies a death certificate cannot be issued until an investigation has been carried out to establish the facts necessary for the certificate to be finalized. The person who carries out such investigations is called a Coroner. Coroners have what is called ‘jurisdiction’ over geographical areas so the Coroner who has charge of a particular investigation will depend on where the person in question has died.  Coroners are appointed by Local Authorities and they are either legal or medical professionals.

What is the purpose of an inquest?

A Coroner must investigate a death in his/her jurisdiction if there is reason to suspect that:

1. The death is violent or unnatural
2. The cause of death is unknown
3. The death occurred whilst the deceased person was in custody (such as a prison, police cell or psychiatric hospital)

The Coroner needs to establish through his/her investigations 

1. who the deceased person was, 
2. when they died, 
3. where they died and
4.  how they died.

Who can take part in an inquest?

At an inquest, family members of the deceased will often take an active role in the process including representatives of the establishment where the death died (if in custody at the time of death) and those who were directly involved in the care of the deceased. It is normal for the parties that are legally represented to receive information from the Coroner prior to the inquest (known as disclosure), receive directions from the Coroner, ask questions of witnesses at the hearing and submit legal arguments to the Coroner about any point of law that may arise.

Will there be a jury?

Inquests are not usually heard in front of a jury; however, there are cases in which it is mandatory. This is the case if the death occurred in the custody of the state and one of the following also applies:

1. The death was violent or unnatural, or of unknown cause
2. The death resulted from an act or omission of a police officer or member of a service police force in the purported execution of their duties
3. The death was caused by an accident, poisoning or disease which must be reported to a government department or inspector

The Coroner does have discretion to call a jury where he/she feels that it is necessary in the wider public interest.

What is a Pre-Inquest Review?

Sometimes it is necessary for the Coroner to hold a hearing before the Inquest called a Pre-Inquest Review Hearing (PIR). The purpose of the PIR is to determine issues before the inquest which will have an impact on how the hearing is held, such as whether Article 2 is engaged and which issues the inquest will address.  The parties may need to make representations to the Coroner about what witnesses will be required to attend at court and to determine whether any further witness statements or records need to be obtained and disclosed. Practical issues such as witness availability and time scale for the hearing may also be addressed. PIR hearings can be an important part of the inquest process as many of the important issues will be decided before the inquest hearing itself begins.

What happens at the Inquest?

Coroner’s Courts vary but they tend to look like an ordinary court room inside. The Coroner will sit at the front of the room and the legal representatives will sit on benches facing him/her. If there is a jury, they will normally be seated to one side of the room so that they have a clear view of the witness box, the legal representatives, and the Coroner. Family members of the deceased will normally sit behind the legal representatives.

The inquest is an inquisitorial process rather than an adversarial one; this means that it is an investigation not a trial with contested opponents. The Coroner and/or Jury will hear evidence from live witnesses who attend at court and may be read witness statements from witnesses who are not present. When a live witness gives evidence, the Coroner will begin by asking them questions, then the legal representatives who are permitted to ask relevant questions to assist the Coroner’s enquiry. If there is a jury present, they are also permitted to ask questions of the witness. Once the Coroner has heard from all the witnesses in relation to the circumstances of the death, the Coroner is then able to call witnesses to address any concerns that have arisen that might give him/her cause for concern that there is a risk of further deaths occurring in the same establishment or in similar circumstances.

At the end of an inquest a conclusion must be reached in relation to the death. If there is a Jury the Coroner will hear legal arguments from the parties as to what conclusions should be left for the Jury to consider. 

Possible conclusions include:

• accident or misadventure (the unintended consequence of an intentional act)
• alcohol/drug related
• industrial disease
• lawful killing
• unlawful killing
• natural causes
• open conclusion
• road traffic collision
• stillbirth
• suicide

The Coroner or Jury may also be able to return a narrative conclusion. This means that they produce a paragraph which factually describes the circumstances of the death. Narratives cannot name any individuals or use words or phrases which apportion civil or criminal liability, but they can be used to make wider comments on any failings or issues which have been raised during the Inquest.