The inquest process, though often misunderstood, serves as a vital function in our justice system, with roots that extend back to medieval England. Charged with investigating sudden, unexplained, or violent deaths, the role of the coroner has evolved considerably from its inception in 1194, transitioning from a tax-gatherer to an independent judicial officer. Laws LJ said a coroner is a judge, but a judge is not a coroner. This transformation reflects the recognition of a fundamental principle: it is in the general interest of the community to investigate any sudden or unnatural deaths, ensuring transparency and justice for all.
A Brief History of the Coroner’s Role
Originally, coroners held significant fiscal responsibility to the Crown. Early duties included investigating anything with the potential for revenue for the monarchy, including deaths by suicide—where property was forfeited to the Crown. Wrecks of the sea, fires, treasure findings, and sudden deaths in the community also came under the coroner’s jurisdiction. These cases served multiple purposes, including ensuring public order and financial benefit for the ruling class.
The early inquest system held another unique purpose: enforcing Norman control over England. After the Norman Conquest, any village where a dead body was discovered could face a hefty fine unless it was proved that the deceased was English, not Norman. This system of “Murdrum” fines introduced the term “murder,” with communities needing to rebut the “Presumption of Normanry” by presenting “Englishry.” This ancient mechanism reflects the early coroner system’s focus on maintaining the social order of the time, often favouring the interests of the elite who controlled the overarching system.
The scope and nature of inquests shifted dramatically by the 19th century as public health concerns arose in response to cholera and other epidemics. The Births and Deaths Registration Act of 1836 responded to public anxiety about the lack of reliable data on death causes. In 1887, the Coroners Act further defined the coroner’s responsibilities, diminishing financial interests in favour of investigating the causes and circumstances of sudden deaths. These shifts paved the way for the modern coroner service, prioritising public safety and justice over revenue.
The Structure and Legal Framework of Inquests Today
Each jurisdiction, of which there are over 70, operates independently, with Senior Coroners and often Area Coroners and or part time Assistant Coroners overseeing cases within their defined areas. This independence is key to the coroner’s duty to conduct investigations without external pressures. Under the CJA 2009, if a death is violent, unnatural, cause of death is unknown or occurs under state custody, the coroner must initiate an inquest to ensure public accountability.
Legal Foundations and Balance of Probabilities
The Supreme Court in the landmark case of R (Maughan) v. HM Senior Coroner for Oxfordshire [2020] set a significant precedent, clarifying that inquests employ the “balance of probabilities” standard for all findings. This contrasts with the higher standard required in criminal courts. Lady Arden’s ruling emphasised that the balance of probabilities standard is sufficient for determining key conclusions, such as Unlawful Killing or Suicide, in line with the inquisitorial nature of inquests.
This decision reflects a pivotal shift in the inquest’s focus, underscoring the importance of fact-finding over punitive judgment. By adopting the balance of probabilities standard, inquests can better serve the public interest by determining the most likely circumstances of death rather than engaging in adversarial legal battles.
The Core Questions in an Inquest
The inquest process seeks to answer four fundamental questions about the deceased:
- Who is the deceased?
- Where did the death occur?
- When did the death happen?
- How did the deceased come by their death?
This fourth question encapsulates “by what means,” the deceased died and reflects the inquest’s focus on clarifying the circumstances rather than assigning criminal or civil liability, which is prohibited.
A fifth question applies where the coroner will additionally examine in what circumstances the deceased came by their death. This arises when there is an arguable breach of Article 2 of the European Convention on Human Rights- the right to life. The test of arguability is low and the court is not permitted to determine whether there is an actual breach.
Interested Persons (IPs) as opposed to parties, such as family members or others closely connected to the death, can participate in the process. However, the inquest remains solely under the coroner’s control, focusing on uncovering facts rather than assigning faults. That said, the coroner’s court is often seen as a gateway court. The police, Health and Safety Executive, Care Quality Commission, Independent Office of Police Complaints and others with regulatory functions and enforcement powers, are often IP’s or attend inquests to observe. Inquests can form the foundation of a civil claim, prosecution or professional disciplinary referral to bodies such as the General Medical Council or Nursing and Midwifery Council. Any of the above would be entitled to request a copy of the recording of the proceedings.
The Duty to Investigate and the Scope of Inquests
Coroners have a duty to investigate deaths that meet specific statutory criteria. When a body is found within their jurisdiction, a coroner must establish if there is reason to suspect that the death was violent, unnatural, of unknown cause or occurred in custody, triggering the need for an inquest. Occasionally, the lack of a body does not prevent an investigation; if enough evidence suggests the likelihood of death, the coroner may proceed based on circumstances alone.
One of the most important aspects of a coroner’s investigation is the “scope,” or the extent to which the coroner will examine the details surrounding a death. There is often strong legal argument over the parameters of the judicial inquiry. While the Coroners and Justice Act does not provide a legal definition of scope, precedent emphasises that coroners must fully, fairly, and fearlessly investigate cases of public concern, especially when deaths involve custodial or state-related circumstances. There is often seen to be a tension between this and the recent case of Morahan [2022] which indicates that inquests should be a “relatively summary process…and not a surrogate public inquiry.”
This is resolved by the coroner enjoying what is known as a wide discretion to decide which issues to examine and which witnesses to call, with each decision guided by what is “necessary, desirable, and proportionate.”
The Process of the Inquest: Stages and Reviews
In complex cases, coroners may hold Pre-Inquest Review (PIR) hearings to discuss sensitive or contentious matters. These preliminary hearings set expectations, determine the scope, and identify potential IPs. PIR hearings ensure transparency and help avoid last-minute surprises, aiming to foster a fair and efficient inquest process. Some inquests can take a few hours, others weeks or months.
Coroners maintain a high level of discretion throughout the inquest process. They are responsible for managing their witnesses, directing the questioning unless they have Counsel to the Inquest, and limiting the inquiry’s bounds, ensuring each inquest stays relevant to its statutory purpose. The coroner’s discretion also extends to document disclosure, which questions can be put by counsel for IP’s and determining whether evidence will be presented orally or in writing. Coroners can use powers under Schedule 5 of the CJA 2009 to obtain evidence, requiring cooperation from IPs, who must provide disclosure and assist in producing relevant information.
Rules of Evidence in Inquests
Inquests operate differently from other judicial proceedings in terms of evidence and parties. Hearsay evidence and opinion testimony are admissible, and cross-examination is not permitted. The style of advocacy is different. In 2021 the Bar Standards Board and Solicitors Regulatory Authority with assistance from the Deputy Chief Coroner published a set of competencies to raise the standard of advocacy in the coroner’s courts. This approach underscores the expertise required in the investigative and fact-finding nature of inquests, in contrast to the adversarial structure of criminal or civil trials.
The rules on self-incrimination also play a unique role in inquests. Witnesses are informed that they may refuse to answer questions that might in the opinion of the coroner, incriminate them, reflecting the inquest’s primary aim: establishing the circumstances surrounding a death rather than pursuing prosecutions. Jury involvement, when required, remains supportive rather than adversarial, with jurors encouraged to question witnesses, after the coroner and advocates, to clarify the facts rather than to assess fault.
Prevent of Future Deaths
An ancillary function of the coroner is to consider whether they have concerns that unless action is taken future deaths will occur. Once such a concern is established either on the investigation or the evidence, the coroner is required to issue a prevention of future death report. It sets out the concerns and requires the recipient to state what action they will take. Such reports cannot make recommendations. The report and response are both public documents which are then published on the Chief Coroner’s website.
Appeals
Where any person or entity is dissatisfied with a coroner’s decision, the process for appeal is limited and indirect. There is no direct route of appeal against the coroner’s rulings, findings or conclusion. Instead, anyone aggrieved by a decision must seek permission for judicial review of that decision, which is conducted before the Administrative Court in the High Court of Justice. The process is strict and governed by the Civil Procedure Rules. The judicial review allows the High Court to assess the rationality of the coroner’s decision, examining if it was reasonable, fair, or made within the scope of the coroner’s powers.
While the Chief Coroner of England and Wales, often a circuit judge, does not have the authority to hear appeals directly or complaints about a coroner at all, they play a key role in guiding coronial practices across jurisdictions and providing judicial leadership, together with 2 deputy chief coroners often made up of a circuit judge and a senior coroner. On occasion, the Chief Coroner also sits as part of a Divisional Court when judicial reviews related to coronial decisions are heard. In very rare circumstances the Chief Coroner can intervene as an Interested Party before the High Court in a judicial review.
The Community Role and Public Interest in Inquests
The coroner system’s evolution from medieval roots reflects its longstanding role in promoting public safety and order. By scrutinising unexpected deaths, inquests serve a broader societal interest, ensuring accountability and providing families and the public with a sense of closure. The community’s reliance on inquests underscores their importance; these investigations not only confirm the facts but also help alleviate suspicions, fears, or misunderstandings about mysterious deaths.
Over the centuries, as legal reforms have reshaped the coroner’s role, the focus has shifted to medical and factual accuracy. For example, in the 19th century, growing concern over uninvestigated deaths due to poisonings and epidemics led to the establishment of death registration laws.
The Future of Coroner Investigations: New Challenges and Reforms
In the 21st century, notable cases, such as that of Dr. Harold Shipman, have highlighted the limitations of current legislation in ensuring robust death investigations. Shipman, a general practitioner convicted of murdering numerous patients, spurred inquiries into how deaths are reviewed, particularly those occurring in medical settings. These inquiries recommend legislative reforms aimed at improving the rigour of inquests and expanding the scope of coroner investigations to address emerging challenges, such as hospital-related deaths or systemic failures in care facilities. The current framework of the coronership, which investigates only a subset of deaths referred for specific reasons, contrasts with more proactive models that some reform advocates suggest. There can be the transformation of an inquest converting into a public inquiry if the government thinks there is sufficient need such as the Manchester Arena Inquiry under Coroner and later Inquiry Chairman Sir John Saunders.
The Enduring Role of the Coroner
From its origins as a tax-collecting position, the coroner’s role has transformed to meet society’s need for impartial, thorough investigations of unexplained deaths. Today’s coroner inquests are vital instruments of public safety, seeking to determine the facts surrounding deaths that might otherwise leave families and communities in uncertainty. Guided by discretion and grounded in legislation, inquests help uphold justice and transparency.
While future reforms may further redefine the scope of inquests, the coroner’s mission remains the same: to explore the truth behind sudden or suspicious deaths and to safeguard public welfare. This enduring commitment to factual inquiry and public service is what keeps the mystery of the inquest relevant in an ever-evolving society, serving as a bridge between the needs of the past and the unknown, and the demands of the future.
David Pojur, Barrister and Assistant Coroner
Author: David Pojur is a barrister specialising in inquests and coronial law. He is recognised by the Legal 500 and Chambers and Partners as a Leading Junior in his field. He sits as an Assistant Coroner, is Counsel to the Inquest and represents Coroner’s in judicial reviews in the High Court. David practices nationally from Lincoln House Chambers, Manchester and Lamb Buildings, Temple, London.
