Inquest (England and Wales)

Inquest (England and Wales)

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". Inquests are the responsibility of the coroner.

Where an inquest is needed

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: ["Halsbury" vol.9(2) 949-950]
*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:"Halsbury" vol.9(2) 939]
*Violent or unnatural;
*Sudden and of unknown cause; or
*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.

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.Department for Constitutional Affairs (2006)]

"With or without a jury?

A coroner must summon a jury for an inquest if the death occurred in prison or in police custody, or in the execution of a police officer's duty, or if it falls under the Health and Safety at Work etc. Act 1974, or if it affects public health or safety. [Coroners Act 1988, s.8(3)] ["Halsbury" vol.9(2) 979] The coroner can also call a jury at their own discretion.

cope of inquest

The purpose of the inquest is to answer four questions: ["Halsbury" vol.9(2) 988] "R v. HM Coroner for North Humberside and Scunthorpe, ex parte Jamieson" [1995] QB 1 at 23, CA] [Coroners Rules 1984, SI 1984/552, r.36]
*Identity of the deceased;
*Place of death;
*Time of death; and
*How the deceased came by his death.

Evidence must be solely for the purpose of answering these questions and no other evidence is admitted. 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 narrower and more limited question. 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. [Coroners Rules 1984, SI 1984/552, r.42] 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. However, the inquest should set out as many of the facts as the public interest requires. [" [ R (on the application of Davies) v. Birmingham Deputy Coroner] " [2003] EWCA (Civ) 1739, [2003] All ER (D) 40 (Dec)]

Under the European Convention of Human Rights, art.2 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 coming into force of the Human Rights Act 1998, in those cases alone, the inquest is now to consider the broader question "by what means and in what circumstances". [" [ R (on the application of Middleton) v. West Somerset Coroner] " [2004] UKHL 10, [2004] 2 AC 182, [2004] 2 All ER 465]

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. ["Halsbury" vol.9(2) 991] ["Re Mitchelstown Inquisition" (1888) 22 LR Ir 279]


Inquests are governed by the Coroners Rules [Coroners Rules 1984, SI 1984/552] [ Coroners (Amendment) Rules 2004, SI2004/921] [Coroners (Amendment) Rules 2005, SI2005/420] The coroner gives notice to near relatives, those entitled to examine witnesses and those whose conduct is likely to be scrutinised. ["Halsbury" vol.9(2) 976] Inquests are held in public except where there are real issues of national security. [Coroners Rules 1984, SI 1984/552, r.17]

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. [Coroners Rules 1984, SI 1984/552, r.20] Witnesses may be compelled to testify subject to the privilege against self-incrimination. [Coroners Rules 1984, SI 1984/552, r.22]


The following verdicts are not mandatory but are strongly recommended: ["Halsbury" vol.9(2) 1030]
*Category 1
**Natural causes;
**Industrial diseases
**Dependency on drugs or non-dependent abuse of drugs;
**Want of attention at birth;
**Lack of care or self-neglect;
*Category 2
**Attempted or self-induced abortion;
**Accident or misadventure;
**Execution of sentence of death;
**Lawful killing (formerly "justifiable homicide");
**Open verdict (no clear cause of death);
*Category 3 - Unlawful killing
*Category 4
**Still birth.

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.

If an open verdict is returned, the inquest can be reopened if new evidence is found and presented to the coroner.Fact|date=September 2007

Inquests into treasure


Owing to dissatisfaction with the current system, and in particular because of perceived failures to arrest the murder spree of Harold Shipman, proposals have been made for reform. [ Home Office (2003a, 2003b and 2004)] A draft bill was published on 12 June 2006. cite web | url= | title=Draft Coroners Bill | publisher=Ministry of Justice | accessdate=2007-10-17 ] The principle draft reforms are:
*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.


External links

*UK-SLD|1345582|the Coroners Act 1989
* [ Coroners Rules 1984] , SI1984/552, as amended and in force as of 21 October 2007. from the Coroners' Law Resource


* web cite | author=Bishop, M. | year=2004 | title=Coroners' Law Resource | publisher=King's College London | accessdate=2007-09-22 | url=
*Department for Constitutional Affairs (2006) PDF| [ "Coroners Service Reform Briefing Note"] |156 KiB
* cite book | title=Coroners Courts: A Guide to Law and Practice | author=Dorries, C. | location=Oxford | publisher=Oxford University Press | year=2004 | edition=2nd ed. | id=ISBN 0471967211
*Home Office (2003a) PDF| [ "Death Certification and Investigation in England, Wales and Northern Ireland, The Report of a Fundamental Review 2003"] , Cm 5831
*— (2003b) PDF| [ "Third Report into Death Certification and the Investigation of Deaths by Coroners"] |191 KiB , Cm 5854
*— (2004) PDF| [ "Position Paper Reforming the Coroner and Death Certification Service"] , Cm 6159, ISBN 010-161592-2
* cite book | author=Levine | title=Coroners’ Courts | year=1999 | publisher=Sweet & Maxwell | id=ISBN 0752 00607X
*Lord Mackay of Clashfern (ed.) (2006) "Halsbury's Laws of England", 4th ed. reissue, vol.9(2), "Coroners"
* cite book | title=Jervis on Coroners | author=Matthews, P. | location=London | publisher=Sweet & Maxwell | edition=13th rev. ed. | year=2007 | id=ISBN 1847031145
* cite book | author=Thomas, T. & Thomas, C. | title=Inquests: A Practitioner's Guide | year=2002 | publisher=Legal Action Group | location=London | id=ISBN 0-905-09997-4

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