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Inquests and care providers - “What you need to know”

  • United Kingdom
  • Health and life sciences


Unfortunately, deaths in care homes are a relatively common occurrence. As such, it’s not difficult to understand why care providers are regularly required to assist a Coroner’s investigation or attend inquests as a Properly Interested Person (PIP) regarding the death of a service user.

Attending an inquest can be a very daunting experience for all parties, especially care providers and staff who have worked closely with the deceased. Care providers are likely to have a number of different roles to fulfil including: the management and collation of documentation for the Coroner, the liaising and supporting of any staff involved, communicating with the family of the deceased and dealing with any negative PR (before, during and after any inquest). In addition, it is now common place for the family to seek to lay the blame at the care providers’ door. Care providers therefore need to exercise caution when engaging with the inquest process.

As a care provider, we’ve set out below some of the key information you should know about the inquest procedure.

What is an Inquest?

An inquest is a public inquiry to examine witnesses on oath who can give any relevant evidence or information in order to establish who the deceased was, and how, when and where they came by their death. The inquest’s task is to establish material facts: there are no parties, sides, prosecution or defence. An inquest is not a trial and the apportionment of blame is not a finding for an inquest to make.

Inquests are held at Coroner’s courts, in public before a duly appointed Coroner. Coroners are independent judicial office holders who are appointed by a local authority within the Coroner’s area. Coroners are usually lawyers, but they are sometimes doctors. All Coroner’s in England and Wales report to the Chief Coroner, His Honour, Judge Peter Thornton QC.

The costs of all inquests are met by the local authority for that area, this includes any costs incurred by a Coroner throughout the inquest procedure including travel, expert’s fees etc.

When is one held?

Less than half of all deaths are reported to a Coroner. However, doctors or the police should report deaths to a Coroner’s office if one or more of the below applies:

  • no doctor saw the deceased during his or her last illness;
  • a doctor is not available to certify the death;
  • the death was due to violence or neglect;
  • the cause of death is unknown;
  • the death was sudden and unexplained;
  • the death was unnatural;
  • the death occurred at work;
  • the death was in other suspicious circumstances; or
  • the deceased died while in prison, police custody or another type of state detention.

As soon as a death is reported to a Coroner, he or she must establish whether further investigation is required to establish the key facts surrounding the death (detailed further below). The Coroner may refer the death to another organisation for investigation if the Coroner thinks it is appropriate to do so, such as the Police, the Health and Safety Executive (HSE), the Care Quality Commission (CQC) or the Independent Police Complaints Commission. In circumstances where a Coroner has referred a death for investigation by another organisation, any inquest will be adjourned until the conclusion of that investigation. This is because the Coroner will want to use the conclusions and results of that investigation to assist him or her in reaching conclusions for the inquest.

If an inquest is required, it should normally take place within six months of the death being reported to the Coroner. A Coroner must report all inquests which are still ongoing after 12 months to the Chief Coroner explaining the reason for the delay.

In some circumstances, particularly for more complex inquests, the Coroner may hold a Pre-Inquest Review (also referred to as PIRs). A PIR is a hearing prior to the inquest to determine any legal issues or discussions regarding the scope of the inquest (see below). All interested parties will have the opportunity to raise any issues, including what you consider the inquest should cover.

What is the purpose of an inquest?

The purpose of any inquest is to ascertain the factual answers to the following questions:

  1. Who is the deceased? – The Coroner is required to establish the identity of the deceased
  2. When did the death occur? – The Coroner must establish a time of death or where a specific time cannot be determined a range of time as to when the death most likely occurred
  3. Where did the death occur? – A place of death will need to be recorded by the Coroner.
  4. How did it occur?– The Coroner is required to ascertain how the deceased came by their death.

As intimated above, an inquest is different from other types of court hearing as there is no prosecution or defence. The sole purpose of the inquest is to discover the facts of the case in order to answer the above questions. There is no apportionment of blame and it is not possible for a Coroner to find a person or organisation responsible for the death. However, if evidence comes to light during the inquest, which suggests that someone or some organisation may be criminally responsible for the death, the Coroner will adjourn the inquest and pass all the evidence to the Police or other prosecuting authority.


Questions 1 to 3 (Who, when and where) are usually relatively straight forward for the Coroner to answer. It is the final question of “how” which presents the most challenge and what determines the overall scope of the inquest.

There are two types of inquest which will govern the Coroner’s approach to the final question:

“Article 2” inquests

In some limited circumstances, Article 2 of the Human Rights Act (the right to life) will apply to the inquest. Under Article 2, case law has established a “general duty” on the state (i.e. public bodies – hospitals, local authority etc) to protect life. Consequently, in circumstances where the Coroner identifies evidence of a breach of that duty by the state, an Article 2 inquest will be held.

For Article 2 inquests, “how” should be interpreted widely as “by what means and in what circumstances”. This is due to a higher investigative duty being placed on the state to investigate the circumstances surrounding the death. That could include investigation into decisions made by public bodies many months prior to the death.

Jamieson Inquests

Inquests which Article 2 does not apply are referred to as Jamieson inquest. At a Jamieson inquest the final question of “how” is given a much narrower interpretation as “by what means”. The inquest still has a duty to fully investigate the death, but any investigation will concentrate on the immediate circumstances surrounding the death.

What conclusions can be reached

At the end of an inquest, once all evidence has been heard, the Coroner will come to a conclusion. The conclusion includes the legal determination (the answers to the four questions - who, when, where and how). When recording the cause of death a Coroner may make use of any of the following terms:

  • accidental or misadventure;
  • alcohol/drug related;
  • industrial disease;
  • unlawful killing;
  • natural causes;
  • suicide;
  • still birth; or
  • open (this is used when the evidence heard means no conclusion can be reached)

A Coroner may also make use of a narrative conclusion which would set out a brief “narrative” of the conclusions he or she has reached. Usually this will set out the facts in slightly more detail and explain the Coroner’s reasoning.

Prevention of Future Death Reports

Coroners are under a statutory duty to make reports to a person, organisation, local authority or government department or agency where he or she believes that action should be taken to prevent future deaths, these are commonly referred to as PFDs. Each year around 600 PFDs are made by Coroners in England and Wales, but numbers are on the rise. If you are subject to a PFD you must respond to the Coroner within the allotted time.

Current trends and conclusions

The proportion of deaths reported to Coroner’s has been relatively consistent over the last 10 years, within the range of 42% and 47% of all deaths. However, the number of PFDs being reported is on the increase. A recent change in procedure means that all PFDs must now be reported and published online, including any responses. In practical terms, this means that they are now receiving more media attention than before.

As an organisation, knowledge and understanding of the inquest procedures is key. Ultimately, the evidence heard before an inquest is public and therefore capable of being reported in the press and being used as evidence in any civil actions. Unfortunately, we now live in a highly litigious society and it has become common place for the family of the deceased to seek compensation from care providers following an inquest.

Organisations should therefore take the time to consider their approach and exercise caution during the inquest process. If in doubt, you should consider legal representation in order to protect your interests.

Tim Hill is a Partner in the Corporate Compliance Team at Eversheds LLP. Should you have any questions please do not hesitate to contact him.

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