Inquisitive about Inquests? Five Common Misconceptions of the Inquest Process

An inquest may be your first ever real world encounter with the legal profession. Whether that be as a witness giving evidence, a family member of a deceased relative or to give your medical expertise. However with that unknowing comes confusion about what happens at an inquest. Some may believe they are going to be staring up at a wig wearing Dickensian figure. Some may believe they will be pestered furiously by a lawyer demanding whether you ‘ordered the code red’ (A few good men).

This is not the case.

This blog will take you through and demystify five misconceptions of the inquest process. For ease sake, any referral to he shall mean he/she.

1. It will just be like a criminal courtroom

An inquest is not like criminal proceedings.

An inquest is a public hearing to establish who, when, where and how a person died. This is not an adversarial process, meaning a battle of two sides. An inquest is an investigation. Its purpose is to look at the facts themselves and conclude what has happened.

There is no prosecution or defence in inquests. The people you see being represented at inquests are called ‘interested parties’. These can be the deceased’s family or a hospital trust for example. To become an interested party, you have to be invited by the coroner.

And most importantly, wigs and gowns are not worn in the Coroner’s Court.

The one similarity that may be seen is that some inquests have a jury. However this is quite rare.

2. The inquest will say if someone is negligent or liable

It is not an uncommon misconception to believe an inquest is the arena to find a hospital negligent or decide if a crime has taken place. However, an inquest is not the place where those conclusions can be reached. There needs to be neutrality and the many inquest procedural rules tightly control this neutrality.

Let’s give a few examples:

  • No witness has to answer a question that may incriminate themselves;[i]
  • The coroner (or jury as mentioned earlier) cannot make conclusions that indicate liability.[ii]
  • The coroner and jury can only express an opinion on who the deceased was, how, when and where the deceased came by his death and if needed, any extra information required under the Births and Deaths Registration Act 2003, such as their place of birth.

Because of the nature of these investigations, it is inevitable that some questions will be asked that stray into negligence territory. For example, why a certain course of conduct was not taken. While these questions may be asked, liability would still not be stated at the end of proceedings.

Neutrality is key.

In potential criminal matters, if it appears that a death is likely to be caused by a homicide offence and that someone could be charged, the coroner will notify the crown prosecution service [iii]. If this is the case, an inquest will usually be suspended pending the outcome of a criminal trial [iv].

Inquests may therefore stray into liability matters. But, any conclusion will be neutral.

3. An inquest has guilty and not guilty verdicts

In the Criminal Justice System, judges give verdicts. Coroners on the other hand, do not give ‘verdicts’; they make ‘conclusions’. This change in terminology was made because people were associating inquests with criminal law. They are not to be compared. As mentioned, an inquest is not adversarial.

But what does ‘conclusions’ mean in a legal sense?

There are two main types of conclusion available to a coroner; short form conclusions and narrative conclusions.

There are nine usual short form conclusions that a coroner may pick from. These are:

1. Accident/Misadventure
2. Alcohol/Drug Related
3. Industrial Disease
4. Lawful/Unlawful Killing
5. Natural Causes
6. Open Conclusion (meaning they cannot be sure how)
7. Road Traffic Collision
8. Stillbirth
9. Suicide

Coroners are encouraged to keep to these 1/2 word set conclusions. [v]

The other type is called a narrative conclusion. These are usually a brief, neutral and factual statement of what happened[vi] e.g. ‘Mr Bloggs was injected with x drug that caused a severe allergic reaction.’

4. Everything has to be proven beyond reasonable doubt

Unlike the criminal world, not every conclusion must be reached on the standard of ‘beyond reasonable doubt’ (99%). Usually, a coroner will work on the civil standard, ‘on the balance of probabilities’ (51%).

There are exceptions to this. Lawful and unlawful killing conclusions must be reached on the criminal standard because matters may stray into criminal proceedings.

Suicide, until recently was also considered on the criminal standard. This was changed recently to the civil standard[vii].

5. Every death has to be dealt with by a coroner

Inquests will only be called in specific circumstances. These may be when cause of death cannot be found by a post mortem or the death is unnatural. For example, if there are questions about what factors caused a death or someone died in violent circumstances in custody. Such circumstances will then be referred to the coroner.

The coroner has the independence to investigate without being under the control of the State. This ensures a fair and impartial process. A coroner will also be in charge of their own court (subject to certain legislation) and will spend most of the time during an inquest asking the questions and doing the investigations. He will decide what evidence is to be called, who he wants to hear give evidence and ultimately, will run the inquest how he feels is most appropriate.

Therefore a coroner does not investigate every death. However if he is referred a death to investigate, he will have near complete discretion on how to go about that.

Concluding Remarks

If you have been asked to appear at an inquest, either to give evidence or as an interested party to the proceedings, it is natural to feel nervous about the prospect. However, with these five myths debunked, you may be able to go into that Coroner’s Court with a little less mystery about the inquest process.

There are a bundle of resources available. Please find below a set of links to them. These institutions are here to help.



[i] Rule 22 of the Coroners Inquest Rules 2013

[ii] Section 10 (2) Coroners and Justice Act 2009

[iii] Rule 25 (4) Coroner’s Inquest Rules

[iv] Paragraph 1/2 of Schedule 1 of the Coroners and Justice Act 2009

[v] Chief Coroner’s Guidance No 17, Para 26 “ Wherever possible coroners should conclude with a short form conclusion. This has the advantage of being simple and accessible for bereaved families and public alike but also clear for statistical purposes

[vi] Jamieson

[vii] R v Maughan