An Inquest is a formal court hearing, conducted by a Coroner to establish how someone died. Not every death leads to an Inquest, as Section 1 of the Coroners & Justice Act 2009 only requires an Inquest to be held if the Coroner has reason to suspect:
- There has been a violent or unnatural death.
- The cause of death is unknown.
- The death was in custody or in state detention.
In most cases, the Inquest will be heard by the Coroner alone, who will ask questions of relevant witnesses and then reach their own conclusions about the key issues. By law, the Coroner is required to establish:
- Who the deceased was.
- Where and when they died.
- The medical cause of death.
In cases where the death arises following direct involvement of the state, the Coroner will also be required to outline the broad circumstances in which the deceased came to die, including whether there have been any failings on the part of the organisations or individuals concerned.
In a small number of cases, the Coroner will be assisted by a Jury of members of the public. An inquest must be held with a jury if the Coroner has reason to suspect:
- The deceased died while in custody or otherwise in state detention, and that either the death was a violent or unnatural one, or the cause of death is unknown.
- The death resulted from an act or omission of a police officer, or a member of a service police force in the purported execution of the officer’s duty.
- The death was caused by a notifiable accident, poisoning or disease (for example a death which must be reported to the Health and Safety Executive).
A Coroner may also hear an Inquest with a jury if they consider there is sufficient reason for doing so.
In many straightforward cases, the Coroner will ask all of the questions. In more complex Inquests, there may be a number of ‘Interested Persons’. These can include the family of the person who died, as well as individuals and organisations who might face criticism about the circumstances leading to the death.
Where an Inquest is considering a death in a care home, the care provider will almost always be regarded as an Interested Person. Individual managers and staff would normally only be given this status if there is some reason for criticism to be made of their personal conduct.
Interested Persons are entitled to be legally represented during an Inquest and their lawyers may ask questions of any witnesses asked to give evidence. It is for the Coroner to decide which witnesses are needed to establish the key issues, taking into account the views of any Interested Persons.
Before the Inquest takes place, the Coroner will obtain as much information as possible. This may include obtaining evidence from the police or regulator, if they have already conducted an investigation. The Coroner will often ask for Interested Persons to provide any relevant documents and can ask potential witnesses to provide a statement outlining any relevant evidence they can give.
In complex cases – for example where there are many witnesses and the Inquest is likely to last more than a few days – the Coroner will hold one or more preliminary hearings. This is to ensure that all relevant evidence has been obtained, to hear the views of the Interested Persons about what evidence is relevant and to fix a date for the Inquest hearing.
The Coroner will ask questions of each witness first and will then allow questions to be put by any of the Interested Persons or their lawyers. Where the witness is legally represented, the Coroner will always allow their lawyer to ask questions last, so that they can clarify any issues that have arisen.
The Coroner may also agree to take into account written evidence, especially where there is no dispute about the contents.
In addition to establishing who the deceased was, when and where they died and what the medical cause of death was, the Coroner or Jury will normally decide on a formal conclusion. In most cases this is expressed by using one of the following descriptions:
- Open verdict.
- Natural causes.
- Alcohol/drug related.
- Unlawful killing.
A conclusion of neglect is perhaps the most frequent outcome to an Inquest that will be of concern to a care provider. This outcome can only be reached where the Coroner or Jury conclude that there has been a gross failure to provide nourishment or basic medical attention to a dependent person. The Coroner or Jury must also conclude that the neglect in question directly caused or contributed to death. Such an outcome will carry with it the clear suggestion that the care provider has failed to provide an appropriate level of care.
In some complex cases (including those where there is State involvement), the Coroner or Jury may provide a narrative conclusion. This can take the form of answers to a series of questions set by the Coroner or a short description of the broad circumstances leading to the death.
The conclusions reached by an Inquest are not permitted to state that negligence has been established or that a named individual has committed a criminal offence. However, the factual conclusions reached may obviously imply that there have been failings by organisations and individuals.
Challenges for providers
If a death takes place while care is being provided or as a result of the care being provided, the Care Quality Commission (CQC) must be notified. Where the circumstances reported raise concerns about the standards of care provided, this may well give rise to an investigation by the CQC even before the Inquest hears evidence about the death.
In cases where there are grounds to suspect that the death arose from negligence or an unlawful act, an investigation may be commenced by the police, who will decide with the Crown Prosecution Service whether a Criminal Prosecution should be brought. Even if there has been no initial police involvement, the Coroner can stop an Inquest if they consider a criminal offence has taken place and refer the matter to the police for formal investigation.
Where the police or regulator conduct an investigation, the Inquest will normally be adjourned until their investigation has concluded and the evidence obtained may be used to assist the Coroner.
An Inquest will almost always be heard in public and will often attract press attention, and an outcome that the death was contributed to by neglect can cause serious harm to a provider’s reputation.
Where there is a finding of unlawful killing, the police and Crown Prosecution Service are obliged to reconsider whether a criminal prosecution should be commenced. Where new evidence of poor care emerges, this may also prompt CQC to reconsider whether it should take action.
Even where there is no outcome which reflects critically on the care provider, press reporting of allegations about the care provided may have a serious impact upon a business.
Giving evidence can be a daunting experience for care home staff, in particular where they face criticism from lawyers acting for a bereaved family. Handled poorly, this can be extremely damaging to staff morale.
An Inquest may also lead to a civil claim being brought against the business, with the process often used by lawyers to obtain information to support their case.
Preventing future deaths
If the Coroner believes that action needs to be taken to prevent future deaths, then they have a duty to make a report to the relevant organisation with the power to action such changes. These reports are intended to improve public health and safety.
A Prevention Future of Deaths report must be made when the investigation or Inquest reveals information which concerns the Coroner that future deaths may occur if an issue is not addressed.
If a care provider is subject to a Prevention of Future Deaths report they must provide a written response to the Coroner within 56 days of the report being sent. The Chief Coroner will then send this response to any interested parties, including CQC or the police if relevant, who then may use the report to inform their own investigations.
What if an Inquest is raised?
It is essential for providers to be well prepared if they are likely to be involved in an Inquest, and early legal advice should be sought.
Lawyers acting for the care provider can liaise with the Coroner and ensure that Interested Person status is obtained, which will enable the provider to play an active part in the preparation for and conduct of the Inquest.
Whenever a death occurs, especially when unexpected, care providers should conduct their own internal investigation, which will later assist in identifying any relevant evidence that should be disclosed to the Coroner. Care providers should take legal advice and consider instructing lawyers to undertake the investigation, to ensure that nothing is done during the investigation to prejudice action that may be taken by the police or CQC.
Members of staff and management who are likely to be called to give evidence will need to prepare witness statements and be familiar with all relevant documents. Advice should be provided to ensure that witnesses from the care provider understand the process and know what to expect.
Consideration should also be given to preparing a statement from a senior manager to demonstrate the steps that have been taken to minimise the risk of a death occurring in similar circumstances, to assist the Coroner in deciding whether a Prevention of Future Deaths report is required.
Legal representation during an Inquest is essential, to ensure the best possible outcome and to reduce the risks outlined.
The importance of Inquests
Inquests involving care providers are an important part of the process to help families of the deceased understand how their loved one died. Establishing exactly what happened and whether appropriate care was provided can help provide comfort and closure for a grieving family.
The Inquest process can also help identify improvements required to ensure that those using care services are kept safe. Where mistakes and errors have been made, it is important that the lessons learned inform best practice in the future.
While involvement in an Inquest can be a daunting experience for a care provider and their staff, with the right advice and careful preparation, any potential reputational and regulatory risks can be minimised.
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