UK: 10 Tips To Remember When Doing An Inquest

Last Updated: 25 October 2002
Article by Leslie Thomas

The purpose of this article is to assist those who are new to the field of inquests and coroners courts. Leslie Thomas has recently co-written a book entitled INQUESTS a practitioner’s guide September 2002 published by LAG ISBN 0 905 09997 4.

Here are my 10 tips for those recently instructed on an inquest.

1. Get the Coroner and his staff on your side?

It might seem obvious that you would not want to alienate the court that you are appearing in front of but it happens all too often. Coroners are like anyone else they want to be liked and appreciated. They have a difficult balancing task to do between competing interested parties. Unlike most other court proceedings during the inquest the venue can be extremely informal. Advocates are sometimes in close proximity to the Coroner and his staff. Getting the Coroner on your side, which simply means, getting him/her to respect you and your client can ultimately pay off dividends. S/he will be more likely to agree to your requests for conference rooms and space to deal with your client, s/he may well be more sympathetic to the death of the deceased and the plight of the family. It is not suggested that it will make the Coroner more amenable to your applications, a good application is a good application and a conversely a badly made application is just that. But it will make the hearing in what is normally very tragic circumstances much more bearable. Especially for your clients. Remember more often than not this is their first time in court. So think twice about the tone of the letter you send, requesting information from the Coroner, or asking for an adjournment or whatever. Remember to say thank you if the Coroner grants an application or request you make at the pre-inquest hearing stage. Be courteous and polite.

2. Explain the procedure of the inquest to the family.

Explain exactly what the family is likely to expect procedurally from the inquest hearing. Explain, the Coroner’s role, what the Court setting will be like. How to address the Coroner and the other representatives? What is appropriate to wear? Who sits where, the layout of the court? If you don’t know your particular court or your particular Coroner, then ask (perhaps the Coroner’s officer). Sometimes it is helpful to suggest to the family that they should go and maybe sit in on an inquest to give them an idea of what to expect. It will make the whole process more bearable for them.

3. Explain the function of the inquest to the family.

In ordinary terms explain what the inquest is about. Explain why inquests are necessary, namely the State’s own investigation into ‘Sudden and unnatural deaths’. Remember to tell them that the purpose of the inquest is to inquire into "who" the deceased was and "how", "when" and "where" the deceased came by his death. Also that it can be a fearless fact finding inquiry and some coroners will not leave any stone unturned. Whereas others will not be as inquiring. Explain rule 43 (Coroners Rules 1984) writing reports at the end of the inquest to prevent similar fatalities. The rule against self-incrimination (rule 22), which applies to certain witnesses, and the rule about documents being read with all parties’ agreement (rule 37). Explain what the verdict is very carefully. Make sure that you explain the distinction between ordinary civil proceedings for instance (negligence action) fault finding and an inquest (non-fault finding). Also the distinction between the inquest and criminal proceedings. Remember most people’s experience of court will be what they have seen on television or in films, and have little bearing to reality.

4. Ensure that the Coroner has proper facilities for recording the evidence

All coroners are duty bound to make a note of the evidence (rule 39). Most high profile inquests are tape-recorded. However, because of limited resources some coroners are still taking notes themselves in long hand!!! The quality of the note taking in some cases leaves a lot to be desired. If you know that the inquest you’re involved in is likely to be contentious for any reason, with the possibility that it might lead to a judicial review or an appeal pursuant to s.13 of the Coroners Act 1988. Make sure that the Coroner has properly facilities for making a note. Suggest that s/he might want to have this particular inquest recorded or get a short hand writer in. Explain with reasons. Most Coroners will understand. The problem is usually one of funding, not an unwillingness to accede to what is obviously a reasonable application.

5. Ensure you take proper notes of the hearing.

More often than not if you have to make an application for judicial review after an inquest, any transcript will not be ready in time before your application for judicial review has to be lodged. A good full note will help you.

6. Ensure that you take the some of the key Coronial cases with you to the hearing

For example: -

R v Humberside Coroner ex p Jamieson [1995] QB 1, R v Coroner for Inner London South ex p Douglas-Williams [1999] 1 All ER 344, , R (Wright) v Secretary of State (2001) 62 BMLR 16, R (application Touche) v Inner North London Coroner [2001] QB 1206, R v Adomako [1995] 1 AC 171, R (application Scott) v HM Coroner for Inner West London (2001) 62 BMLR 222, R (application Dawson) v HM Coroner for Kingston- upon Hull (unreported), R (application N) v Liverpool Coroner [2002] ACD 13, R (application Bentley) v Avon Coroner (unreported, 2001] All ER (D) 37 (Mar) ) , R (application Amin) v Secretary of State for the Home Department and R (application Middleton) v HM Coroner for Western Somerset [2002] 3 WLR 505, R v HM Coroner for Southwark ex p Fields (unreported).

The above list is by no means exhaustive, but a suggestion of some key cases in recent years the advocate ought to be aware of.

7. Ensure that you take one or more of the following books with you

Jervis on Coroners (Major text but hopelessly outdated and not very good on human rights), Dorris on Coroners Courts (good informative book with a fresh approach well respected by Coroners) Levine on Coroners Courts useful materials on drugs, asphyxia and restraint. Thomas, Friedman and Christian ‘Inquests a practitioners guide’, new LAG publication. Written by practitioners for practitioners. Extremely useful chapters for example on the hearing and human rights.

8. If you’re new to Inquests seek help from others with experience

Get in contact with INQUESTS; better still join the INQUEST lawyers group. If you’re a solicitor instruct counsel with experience. If you’re counsel ring up other counsel and speak to them about the hearing, and some of the pitfalls.

9.Have in mind your post inquest remedies at the hearing itself so you know what to do if the Inquest does not go how you expected.

Remember judicial review is the process whereby the High Court ‘supervises’ the activities of public bodies (for example Ministers, tribunals, magistrates courts, and Coroners courts) when they act or make decisions outside their powers or fail to perform their duties. These powers and duties are imposed upon them by Parliament, and the constitutional role of the courts is, in theory, to uphold the will of Parliament. When a public body fails to do, as it should it is said to be acting unlawfully. Potential public law challenges to the scope of the inquiry and evidence

If the Coroner: -

(a) Omits or refuses to call a particular witness.

(b) Omits or refuses to obtain medical evidence.

(c) Refuses to grant an adjournment.

(d) Omits or refuses to seek documentary evidence.

Arguably in the above situations there may be insufficiency of inquiry into the statutory matters the Coroner is duty bound to investigate, 'who', 'where', 'when' and 'how' the deceased came by his death. The above would give rise to challenges by way of judicial review for failing to make sufficient enquiries, breach of statutory duty, breach of rules of natural justice, failing to take relevant matters into account or unreasonableness.

Secondly, you could consider an appeal against the Coroner under s.13 Coroners Act which permits appeals when an applicant (who may be any interested party) dissatisfied with the inquest proceedings, or lack of proceedings, can apply to the senior law officer, who will consider the complaint and decide whether there are sufficient justifiable grounds for recommending that either: -

  • There should be an inquest; or
  • A fresh inquest should be held.

If the Attorney General gives his recommendation, then the matter is referred to the High Court for a final determination of the matter. Accordingly, like judicial review proceedings, it is a two-stage process.

The grounds for a s.13 application are

  • There has been fraud
  • Rejection of evidence (this would tend to suggest inter alia, some intentional act possibly by the Coroner, such as the withholding or suppressing of evidence which should have been submitted at the inquest but was not)

  • Irregularity of proceedings (for example a failure to follow the Coroner rules, for instance if the coroner failed to hold the inquest in public, or failed to notify interested parties of the inquest arrangements, or failed to notify an individual whose conduct was likely to be called into question, or refused an adjournment when it became apparent that such a person was not present)
  • Insufficiency of Inquiry (for example a failure by the Coroner to properly and adequately explore the circumstances surrounding the death in accordance with r.36 CR)
  • Discovery of New Facts or Evidence or otherwise. (For example, new information comes to light after the inquest, which would affect the verdict reached; this could be by way of new witnesses, medical evidence, forensic evidence etc.)

10. Remember the press/media will be interested in most controversial inquests

Do not forget to advise your clients about this. You must also learn how to handle the media. An improper comment reported in the media can be damaging and potentially detrimental to the inquest hearing. Consider carefully whether you want to release a press statement before hand. If you are new to this seek advice on the subject. Speak to INQUEST the organisation 89-93 Fonthill Road, London, N4 3JH (Tel 020 7263 1111) who regularly has to deal with the media. Ensure that you respect the families wishes vis a vis the media.

The content of this article is intended as a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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