An introduction to inquests

Show notes

Explore the inquest process with insights from David Lewis, a seasoned regulatory lawyer and coroner. David explains why inquests are conducted and what happens during an inquest.

Transcript

James Muller: Hello, and welcome to the third of Weightmans safety season of podcasts.

James: Today, your speaker is David Lewis, who's going to be giving you an overview of inquests.

James: Keep an eye out for another episode on inquests later in the series.

James: Please do remember to leave any questions you have in the comments, as in our eighth and final episode, we'll be answering some of your questions from throughout the series.

James: Over to David.

David Lewis: Hello there. Thank you for joining me for the next in our series of podcasts. My name is David Lewis. I'm the senior partner here at Weightmans I'm a regulatory lawyer, and I've been representing clients, appearing at inquests since the late 1980s, I’m sorry to say.

David: I'm also a coroner in my own right I sit here in cases in the coroner's court in three different areas in the northwest and North Wales. So here today just to give you an overview into the Inquest process and tell you a little bit about why we have Inquests, and what it looks like when they take place.

David: So why do we have an inquest in the first place? And of course, you'll be aware I'm sure that not all deaths are reported to the coroner.

David: And perhaps it were also that not all deaths that are reported to the coroner necessarily result in a full inquest taking place.

David: When the coroner receives a report that a death occurred in their coroner area. They have to make an initial decision as to whether it's a case which warrants further investigation.

David: And that decision is based upon establishing quickly, first of all, whether the cause of death is unknown. If the cause is unknown, then an investigation will be necessary. Or secondly, whether there's any reason to suspect that the cause of death might not have been entirely natural.

David: So for example, it may a death arising from an accident, or it may have been a death occurring in other specific circumstances such as somebody dying in state detention where there would be expectation of an investigation taking place. So that's the first point at which the coroner becomes involved. The death is reported. Decision has made investigation card yes or no. If an investigation is required because the cause of death is unknown or because it fits into the potentially unnatural situation, that investigation begins. So that investigation will often commence with the coroner for a post mortem examination of the body of the person who's died. So that involves instructing a local pathologist to conduct an investigation. There are different levels of investigation depending on the nature of the case. But fundamentally, the report that comes back, will give the coroner an indication of the medical cause of death.

David: That, itself may be supported by additional investigations such as histology, which will be involved in taking small samples of body tissue for examination.

David: Under the microscope, it may involve toxicology taking samples of blood and urine typically, to analyse them for the potential presence of alcohol and drugs in particular.

David: And those things will then be captured and included within the pathologist postmortem report to say, I think from medical perspective, this is how the individual came by their death. So, at the early stage in that investigation process, the coroner receives the post mortem report, if a post mortem been arranged, and can then take a fresh view as to whether or not this is a death from a natural cause. So in practice, lots of deaths come to us and we don't know why somebody's died. There may be a suspicion that there's been something unnatural, but you can't be sure. And very often, the postmortem, report for the pathologist will say, actually, no. This was an entirely cause of death, whatever the circumstances that really this person's died from some natural underlying disease process for example, they may have suffered a heart attack that may have, had a long term condition which hadn't been known previously, for example.

David: Ordinarily, if the postmortem report comes back and says this was a natural cause of death, that will usually end the coroner's investigation completely. And at that point the body is released for, burial or cremation by the family and the file is put to bed as far as the coroner is concerned.

David: But if that isn't the situation, if there is still some continuing reason to suspect that this death may not have been entirely natural, the coroner's investigation continues.

David: Typically, that will involve the coroner's officers who may or may not be part of the local police service, making inquiries on the coroner's behalf in the background. So obtaining statements and reports and documents from people who may be able to assist, preparing a file, which the coroner will then review, before deciding that the case is ready to proceed to inquest.

David: Sometimes that decision to proceed to inquest will be preceded by what's called a pre request review. So, part way through the investigation process, the coroner may say to the officer, can you please list a pre review. We'll get all the people who may be involved in the in question due course, to come before me, and we'll have a discussion about what further directions might be relevant. For example, to identify the scope of the inquest, which facts and issues will be considered at the same question which go beyond the coroner's remit.

David: Which evidence do we need? Which witnesses would be able to call how long will the case take? Where will the case be heard and so on? So that's a pre request review hearing. They're not mandatory, but they're very often helpful particularly in the larger and more complex cases.

David: So all of that has happened before we ever get to an inquest itself.

David: At the inquest itself, the coroner's duty is actually quite limited and it's defined by law. So the first thing to understand is that this is the coroner's hearing, there are no sides in an inquest. There are no parties in an inquest. It's a fact finding investigation or to use the language that we sometimes use, this is an inquisitorial process we're inquiring into what happened.

David: It's not an adversarial process where you have as you would in other courts. One side against another. So just to add a little detail to that, for example, if a case is involved in proceedings in the crown court, a criminal case, you would have the prosecution against the defense, and they would each call their respective witnesses to give evidence on their behalf. In a claim for compensation in the civil courts, you'd have the claimant and the defendant that these call their respective evidence and make out of their case.

David: In the coroner's court because there are no sides, and because it's the coroner's investigation, the coroner will decide which witnesses he or she wishes to hear from, and we'll call them to give evidence. And the evidence of the inquest is then all directed towards fulfilling the coroners statutory duty, which is to establish from the evidence that is heard in court.

David: First of all, the answer to four limited but important questions.

David: The first three of which rarely causes any difficulty. So first of all, who is the person who died? So it's very rare that we're involved in a case where there's a question mark over the identity of the body. So Question one: who died?

David: Questions two and three, when and where did the individual come by their death? And again, in the vast majority of cases, we know before we get into court, exactly when somebody was declared dead, pronounced dead, and where that occurred. So the place and time of death are not usually commercial. It's the fourth question that the inquest is really all about.

David: How did the individual come by their death? And we try to answer that question how by bringing together two things.

David: One will be the medical cause of death. Often of the post mortem report, sometimes a hospital doctor, for example, may have been able to give an opinion as the medical cause of death and avoid the need for a post mortem at all. But we bring together the answer to that question, what's the medical cause of death? And then behind that in the background, what was the broad underlying sequence of events that led to or brought about the death? So if I give you an example, suppose somebody were to be run over crossing the road outside the office this morning.

David: The post mortem report would have probably say that they died from injuries consistent with a road traffic accident. So that answers the medical cause of death, but we'd want to explore how the accident occurred. The car traveling too quickly and did the pedestrian step out in front of the car? Was there any other third party involvement? What was the broad sequence of events that led to that accent occurring? So the answer to the question how is a combination of those two things, the medical cause of death and the underlying sequence of events.

David: The coroner will have lots of discretion as to how much detail to go into. So on the one hand, inquests are not intended to look beneath every stone along the way.

David: The chief coroner has recently explained that, you know, the inquest is intended to be a relatively summary process. It should be quite short. It should be limited. It should be focused on the key issues who died when where and how.

David: But sometimes cases do require investigation of wider circumstances.

David: We may, for example, let's take a death in a care home or a death in a hospital setting there may well be some analysis of the policies and procedures that were in place in that setting to see whether they were adhered to. And if not, whether that played any part in the death arising.

David: It may be a case in which, article two is engaged. I'm talking now about article two if you being convention on human rights, which is essentially the right to life. This is a very complex area in its own right and certainly gives beyond a short introductions such as today, but in cases where article two is engaged, typically cases involving agents of the state.

David: There may be a broader requirement corner to explore the wider circumstances, not just the direct chain of events that led to death. But the coroner makes a decision about the scope and the coroner decides which witnesses need to be presented in court. And worth noting at this point that witnesses can give their evidence in court in one of two ways. They can be called to the court itself and give evidence on the witness stand in the way that you might expect from a court hearing, but in certain circumstances, it may be possible for the evidence of a witness to be given in documentary form under the document to be read out or summarized by the coroner in court.

David: It's not a right on the part of a witness to do that, but there are certain circumstances in which that procedure can take place. Most typically either because the witnesses unavailable, for example, They may be out of the country or they may have died since they gave their evidence, or otherwise because their evidence isn't controversial, and it's unlikely that anybody would have any questions for them in any event. In other words, their statement covers everything in sufficient detail to assist the court.

David: So witnesses give their evidence in one of two ways. Who do they give it to? Well, the person who presides over the inquest I should have gathered by now is the coroner.

David: We may have the senior coroner who will be the person who runs the coroner area, there may be an area coroner, typically a full time employed coroner who will support the senior coroner in his or her work. And finally, it may be as with myself, an assistant coroner, somebody who's part time and comes in to handle cases from time to time.

David: We're all independent judicial officers. So as an assistant coroner, I don't deal with the case according to what the senior coroner has told me to do. I deal with it and obligation to deal with it independently, myself based upon, my own interpretation of the facts of the case.

David: So, as far as you're concerned, it doesn't matter whether it's a senior coroner, an area coroner, or an assistant coroner, the coroner will hear the case, and it makes no difference.

David: Where does it take place? It takes place in a coroner's court, and coroner's courts are in each corner area.

David: Today, unlike when I began practicing in the 1980s, most coroners will have a dedicated courtroom where they will hear most of their cases, but cases can be heard in any number of settings. In the court where I sit mainly, we have a large set piece courtroom, which would look very much like a courtroom you might see in the criminal courts or the civil courts. But we also have a smaller meeting group, effectively, with a big table and sometimes smaller requests, less formal hearings with fewer witnesses may take place there. Not least because that may be a more sensitive environment for those less formal cases. But either way, it amounts to being the coroner's court. So, the coroner presides over an inquest in his or her court, and the coroner decides which witnesses will be called to give evidence.

David: And when they do give their evidence, and we have a further podcast, that will follow mine coming from, to my colleague, Sophie and Lily to talk about giving evidence the coroner's court, but it's the coroner who will first of all ask questions of all of the witnesses.

David: But also in court with the coroner will be any, Interested Persons, and that's a technical term, capital I, capital P, Interested Persons. And that means people who in the eye of the coroner are sufficiently interested in this in quest to be allowed to participate in it. And participation means fundamentally two things. The first is that they'll be allowed to see in advance of the hearing any disclosure, which the coroner is able to provide. So, the coroner will send to the interested persons before the hearing copies of the statements and reports and other documents that may be referred to in court so that they can prepare themselves for what will take place.

David: The second entitlement that you have as an Interested Person is the entitlement to ask questions of the witnesses when they give their evidence.

David: So, in every case, close family members of the person who died will be treated as Interested Persons. And when the coroner has finished asking his or her questions of any individual witness, the family will be asked whether they have any questions.

David: Important to note, however, that the only questions that can be asked by any Interested Person must be questions that assist the coroner in the discharge of his or her function. So, the questions have to relate to the four questions who died when, where, or how did the death come about?

David: Other questions, which may, for example, you know, attack the, the manner of which an individual witness has dealt with people in the past, you know, they were they were grumpy, they were unhelpful.

David: In hospital settings, you often hear sort of complaints. Well, when one was in hospital, they didn't bring us sandwiches on time every day. Well, that might have been, you know, perceived as poor care in a hospital setting, but it doesn't help us to identify who died when where or how. So, it's not actually, a relevant line of investigation in the coroner's court. So, you would expect your coroner to allow a little leeway, particularly these family members to raise some issues around that, but technically anything that goes outside the proper remit of the coroner's court should not be allowed.

David: So, family members will always be Interested Persons, others may be. So, in the case of somebody who's died in a workplace setting, for example, the employers would be considered an Interested Person, as would the Health and Safety executive or the local authority environmental health officer if they're conducting their own inquiries. And there's a lengthy list in the Coroners and Justice Act that sets out who falls within the definition of being an Interested Person and is entitled as a right to participate with a catchall provision that says and anybody else who the coroner thinks has sufficient interest may also participate.

David: So, that means that we have, potentially a number of people asking questions of each witness who attends, but all of those questions have to be directed towards ensuring that the coroner's in a position to answer the four statutory questions at the end of the case.

David: In addition to the four statutory questions, the coroner also has an obligation in law to record the registration particulars that are necessary for registration purposes. That's usually very routine. It's capturing the date and place of birth, the date and place of death, and other personal details about the news died. Those things are usually routine.

David: I've said that the coroner will preside over the hearing there's a small number of cases in which the coroner will sit with a jury, but let's be very clear now. There is a big difference between, an inquest and a trial, and the role of a jury in an inquest is not the role of a jury in a criminal trial. So, let's just explore a little bit.

David: The coroner's job in a fact finding investigation is to find the answers to the four questions and to record the registration particulars.

David: The law is very clear that having conducted the inquest, the coroner is not in a position to express an opinion about anything else.

David: The role of an inquest is not to attribute blame or a portion blame between different organisations or individuals.

David: It's not to find anybody negligent as you would in civil proceedings or guilty as you would in criminal proceedings. No part of the coroner's process. So, the inquest is not there to establish those things that dealt with in other jurisdictions where different rules of evidence, different rules of disclosure, procedural rules apply. So, the coroner's rule is very limited.

David: It is not to portion blame, and the rules again are specific about that that's not permitted nor can you identify criminal liability on the part of any named person? So, the coroner's not interested in doing any of that. The case is in which a jury sits with a coroner then, the jury's role is very different to in a criminal case. So, in a criminal case, a jury decides guilt or innocence a person who's charged with an offense.

David: In the coroner's court, if a jury is required, then the jury's role is to establish who died when where and how? The coroner's role changes to being one of managing the process of calling the witnesses for the jury to hear.

David: So, the jury's obligation is simply to find the facts of the case and having found the facts of the case, ultimately to reach a conclusion.

David: So, what do I mean by a conclusion? We've not mentioned that before. Well, I'll come to that in a second, but let me just finish off this point about the role of a jury first of all. Juries are required in a very small percentage of cases. It's certainly fewer than ten percent of requests. I think it's probably fewer than five percent of requests. I don't have the front of me just today.

David: But they're normally limited cases of people who've died, for example, in state detention so they may be in prison or in police custody would require an inquest.

David: Cases where there's an obligation to report the death will notify government department or inspector. So typically, for example, a death in the workplace where there would be notification to the health and safety executive. That would require a jury.

David: And cases where the death is, there's reason to suspect that the death has resulted from the act or an omission of a police officer in the course of the execution of their duties. Again, that would require a jury.

David: But to emphasise the jury's job is not a fan or innocence, it's to answer the questions, who died when where and how and to reach conclusion.

David: So what do I mean by a conclusion? Well, at the end of the case, the and has to reach a conclusion as to how the death occurred. In the past, years ago, confusingly, we used to call that process the verdict, and we specifically taken the word verdict out because confusion with what goes on in the criminal courts. We call it the conclusion. And if you've seen newspaper reports or heard radio or television reports of the conclusion of inquest in the past, you may have heard words like, conclusion, accidental death, death by misadventure, death by suicide. There are a number of specified examples of what we call short form conclusions, little labels that could be used to describe how the death occurred.

David: I'm not going to go through them all today. Those are some examples. There are others.

David: You could die as a result of industrial disease, you could have an a whole or drug related death. You could, of course, die from natural causes. You may die in a road traffic collision and so forth. And actually, there is no limit to, although there is a list that's provided to coroners and the rules as examples of the short form conclusions that are appropriate.

David: Coroners have a free hand to reach any conclusion they wish.

David: And sometimes the conclusion might be what we call a narrative conclusion where a few sentences would be used to describe the circumstances If we think, for example, that simply saying accidental death may feel a bit clumsy and not properly describe how the death occurred, we might use a sentence or two, to describe conclusion to the case instead.

David: So the coroner will invite representations from the lawyers before, the court in any case at that stage to say would you like to address me as to which conclusions I can properly reach in this case based upon the evidence we've heard. What the lawyers can't do is to address the corona with the closing speech based on the facts. You know, based on what so and so said, I think you should reach this. That should be preferred to what so and so said. We're not allowed to do that, but we can address the coroner's to say on the law, it would be safe for you to reach this conclusion in this case. And then the coroner will go away, reflect upon the evidence and come back and say, these are my findings. This is the conclusion that I've based upon them.

David: The coroner's findings will be reached in the coroner's court on the balance of probabilities. Is it more likely than not that a particular point has been established? So we don't have the criminal standard of things being proven beyond a reasonable doubt. The coroner makes findings affect on the bounds of probabilities and reaches a conclusion on the balance of probabilities.

David: Along the way, the coroner has another function, and that is to think about whether there is any learning possible from this case which should result in the coroner sending what's called a prevention of future deaths report. So if the coroner has heard us something that has occurred, and is concerned that should that reoccur or continue that other lives could be at risk. The coroner has a duty to write a report to somebody who he thinks can do something about it.

David: So not to make recommendations because at the end of an inquest, the coroner hasn't suddenly become an expert in that area, but the coroner can say, I've heard that this death a that, when Mr or Mrs X was working your factory, and I've heard about these situations around the inadequacy of your risk assessments, let's say, I have a concern that if you don't get this right, somebody else could die, what are you going to do about it? And the person who receives that report then has fifty six days in which to write back to the coroner, with an explanation for how they're going to address the concerns that the coroner has raised.

David: So of itself, it's not a sanction. It's the coroner taking advantage of the opportunity, but being required to take advantage of the opportunity to say there's an opportunity for learning here, what can we learn?

David: Just a couple of other points along the way if I may before I conclude. So, Of course, somewhere between the opening of the investigation by the coroner when evidence is being gathered and the hearing itself, those who are thought to be able to assist, will first of all have obligations to provide disclosure to the coroner. In other words, to give the coroner copies of material documents that are in their possession.

David: And in particular, if you're acting, or if you're associated with a public body, local authority, it may be a government agency or whatever. And there will be a high expectation about your willingness to explore what documents you have and to volunteer them court and to do so with candour. And that also applies to witness statements. The coroner will have an expectation that the witness statements that you provide to assist the investigation will be candid and will be open. And fundamentally, we'll be honest. So remember when you come to give your oath in the hearing in due course, you'll promise to tell the truth the whole truth and nothing but the truth, and you should bear that in mind when you're preparing your witness statement. We can certainly assist you with how to go about that process and how to set the witness statement out in a way that's most likely to assist the court, but fundamentally remember you must tell the truth.

David: There may also be an opportunity to make some submissions to the coroner either at a pre inquiry request review hearing or in writing about the scope of the inquest or how it be held.

David: Those are matters that your lawyers will be able to assist you with.

David: So we've had our request. It may have lasted half an hour. It may have lasted several weeks. I'm sitting next week to hear a case that's listed with a jury for two weeks. That's relatively unusual. The majority of cases are short.

David: Perhaps half a day, perhaps a day.

David: Rarely the hearings last longer than that. But it all depends on the complexity case and the number of witnesses who need to be involved.

David: I will say one further thing and, say my colleagues would give a further short podcast around some answers to frequently asked questions about, appearing at an inquest to give evidence.

David: The one thing I would say, and I said there's actually to a witness just yesterday, I think probably 98%, I pulled the figure from the air, but it's about right. Ninety eight percent of those people I've represented had inquest come away from court saying, you know, it wasn't as bad as I thought it would be. And indeed the witness yesterday confirmed the same. So, whilst you're there to assist in a formal court proceeding, with proper support and with help and with somebody to look after you and explain what's going to happen. It's not something you should dread.

David: I think that's probably as much as I can cover in the time available very much for listening. I hope there's been some assistance. So my name is David Lewis. If you have any queries, please feel free to contact me. You'll get my details from Weightmans website. It's david.lewis@weightmans.com. Thank you now.

James: Thank you for that, David, and thank you all for listening to weightman's safety season of pot casts.

James: The second inquest's podcast will return in two weeks, but next week's podcast will be look both ways, transport, and fleet risks. So make sure not to miss that available from the 19 February.