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DEMYSTIFYING INQUESTS: WHAT ARE THEY AND WHAT HAPPENS?

Having to attend an inquest can be a harrowing experience, but the process can help to answer questions about the death of a loved-one. Adam Hodson is an assistant coroner and clinical negligence expert at Lanyon Bowdler, which has offices in Conwy and works with people across North Wales. He explains what an inquest is for, and how the process works…

What is a coroner?

A coroner is essentially a judge who is responsible for investigating deaths in very specific circumstances, such as when the cause of death is unknown, a result of a violent action, occurred when in prison or state detention, or where there is reasonable cause to suspect that a death was unnatural.

What does an inquest find out?

An inquest is a fact-finding inquiry, and it’s important to understand that it does not set out to determine whether anyone was at fault for a person’s death. An inquest will answer four key questions: who died, where, when and how did they die? The answers to the first three questions are usually already known, so the inquest will spend most of its time determining the answer to the last question.

A coroner colleague put it well when he said: “They officiate at the end of things. They examine the departure, they document the last moments of life and the small slither of the world that surrounded it.”

Can an inquest find blame?

For the majority of inquests, the answer is no – and that can be quite difficult for families to deal with, because they want to hold a person or organisation to account, but an inquest is not the place to do that.

During the evidence, the coroner will examine the medical treatment which the patient received and in doing so will identify – in public – any shortcomings in care which contributed to the death. So in real terms, it does feel like they apportion blame, but the legal paperwork cannot identify blame or fault.

What is the inquest process actually like?

The first thing to understand is that it’s not like what you see on the TV! It is not a criminal trial. At its core, it’s a collaborative process with everyone meant to work together with the coroner to enable them to investigate the circumstances of the death.

Increasingly, elements of the inquest – or sometimes the whole process – can be carried out using video conferencing like Zoom or Teams, which can make things less daunting for families who can speak to the coroner from home.

Who gives evidence at an inquest?

That’s ultimately up to the coroner, but it will usually involve members of the treating medical staff if the death occurred at a hospital. The coroner can request a statement summarising the care a person received, rather than questioning multiple witnesses. This can make things easier but can sometimes be frustrating for families because they won’t hear directly from some of the people who were involved in the care of their loved one.

Can the family give evidence?

The whole point of an inquest is to put the family of the deceased at the heart of the process, so if the family is prepared to do so, then yes they absolutely should have the opportunity to give evidence.

What conclusions can be made at an inquest?

Coroners have a lot of options open to them when they make their conclusions. They can give what is known as a shortform conclusion, which is a set of words to determine the death, such as “suicide” or “accidental death”, or they can give a narrative conclusion, which enables the coroner to give a brief, neutral and factual statement, which addresses the issues central to the death.

Occasionally, the coroner can give a finding of neglect, meaning there was a gross failure to provide a basic level of care which led to the death, which is clearly very significant in clinical negligence cases and is the most damning judgement. n